Glossary
Medicare Fraud
Knowingly billing Medicare for services that were not provided, not needed, or billed at a higher level than delivered, or paying kickbacks for patient referrals. It is pursued through criminal charges and the False Claims Act.
Medicare fraud means intentionally deceiving the Medicare program to get paid. Common schemes include billing for services never provided, "upcoding" a visit to a more expensive code, billing for medically unnecessary tests or equipment, falsifying diagnoses to raise payments in Medicare Advantage, and paying or receiving kickbacks for referrals. The federal Anti-Kickback Statute makes it a crime to knowingly and willfully offer or receive anything of value in exchange for referring patients for services paid by federal health programs.
The main civil tool is the False Claims Act. Under 31 U.S.C. 3729, anyone who knowingly submits a false claim to the government is liable for a civil penalty of $5,000 to $10,000 per claim, as adjusted for inflation, plus three times the government's damages. Because health care providers submit huge numbers of claims, those penalties add up quickly.
Private citizens can bring these cases. Under the False Claims Act's qui tam provisions, a whistleblower, often a current or former employee, files a sealed lawsuit on the government's behalf. If the government takes over the case, the whistleblower receives 15% to 25% of the recovery; if the government declines and the whistleblower proceeds alone and wins, the share is 25% to 30%. The law also protects whistleblowers from retaliation.
Patients can help by reviewing their Medicare Summary Notices and reporting charges for care they never received to the HHS Office of Inspector General. See our page on whistleblower and qui tam lawsuits and our term page on retaliation.
Related on Best Class Actions
Sources.
Statutes, court rules, appellate opinions, and bar publications we relied on. See our editorial standards.