In an effort to curb Medicare fraud, the government codified law and promised to pay people who provide tips or inside information leading to fraud. Through this move, even ordinary individuals like you can participate in reducing crime and shedding light on undetected fraud that has plagued the health care system over the years.
That being said, you would not only be doing an important public service by shedding light on undetected crimes, but you would also receive money from the government by providing such valuable information.
With that, it is important to further understand Medicare fraud rewards as well as the other benefits and protection that comes along with it. In this article, we would discuss a few things you need to know about Medicare fraud rewards, what is it, how much would you get, how you can get it, whether you are eligible or not, and so on.
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Medicare fraud rewards
Before we delve into further detail, let us first discuss what Medicare fraud reward is.
To put it simply, it is a codified federal regulation where the Center of Medicare and Medicaid Services (CMS) and other branches of the government are required to pay anyone who provides tips or information leading to fraud.
So if you provide valuable information to the government, then by law, they are required to pay you a monetary reward.
That is basically the premise of this law.
However, as with any laws and regulations, the application of this law in real life tends to get blurry and confusing once you look at the details and try to interpret it.
You cannot expect CMS to pay you immediately once you provide tips or valuable information. There are certain levels you have to go through and criteria that you have to meet before you get your monetary reward.
On top of that, shedding light on an undetected fraud is not an easy feat. You also have to take into consideration the repercussions and consequences of the information you would be providing to the authorities.
With that, we highly suggest you consult with an experienced legal practitioner first. You can read this article further if you want to know more about Medicare fraud rewards so that you would know what to ask in your consultation with a lawyer.
Nature of the rewards
As a general rule, individuals or entities who provided valuable information related to Medicare fraud and abuse are entitled to receive a monetary reward.
The amount of reward is usually at the discretion of the CMS and it can vary depending on the case or lawsuit.
For example, whistleblowers like you can earn a 6-figure payout if the case is related to the Federal False Claims Act. Cases like these can be high stakes for all parties involved since litigations are usually expensive and can span for years. Upon settlement and when the case is successful, whistleblowers are entitled to 15–25% of the recovery amount if the government intervenes. But as per the Qui Tam Lawsuit, if the government does not intervene in the litigation and the case is still successful, whistleblowers are entitled to as high as 25-35% of the recovery amount.
With federal laws like the False Claim Act, whistleblowers like you are able to initiate and facilitate lawsuits in place of the government. Given that federally administered programs are not perfect and cannot detect all fraud in the system, incentivizing whistleblowers this way would help relieve even a bit of pressure on both our healthcare and legal system.
Determining the amount and payment scheme of the reward
- The CMS would determine the eligibility and the amount of the reward based on the significance of the information provided.
- The amount of a reward represents what CMS considers to be adequate compensation in the particular case, not to exceed 10 percent of the overpayments recovered in the case or $1,000, whichever is less.
- If more than one person is eligible to receive a reward in a particular case, CMS allocates the total reward amount among the participants.
- The CMS would determine the amount of the reward based on the recovered Medicare payments
- CMS makes payments as promptly as the circumstances of the case permit, but not until it has collected all Medicare overpayments, fines, and penalties.
Eligibility to receive rewards
Now that we have established that the amount of Medicare fraud reward can reach up to millions of dollars, let us now determine whether you are eligible to receive it or not.
According to the Electronic Code of Federal Regulations, there are two types of eligibility you have to take note of. First is the eligibility of the information you provided and the second is your eligibility to receive the reward.
Information Eligible for reward
(1) In order for an individual to be eligible to receive a reward, the information he or she supplied must relate to the activities of a specific individual or entity and must specify the time period of the alleged activities.
(2) CMS does not give a reward for information relating to an individual or entity that, at the time the information is provided, is already the subject of a review or investigation by CMS or its contractors, or the OIG, the Department of Justice, the Federal Bureau of Investigation, or any other Federal, State, or local law enforcement agency.
Your Eligibility to receive a reward
You are eligible to receive an award as long as you submit the proper required information and you are not included in the list of excluded individuals
Excluded individuals
- An individual who was, or is an immediate family member of, an officer or employee of HHS or its contractors, the SSA, the OIG, a State Medicaid Agency, or the Department of Justice, the Federal Bureau of Investigation, or any other Federal, State, or local law enforcement agency at the time he or she came into possession of, or divulged, information leading to a recovery of Medicare funds is not eligible to receive a reward under this section.
- Any other Federal or State employee or contractor or an HHS grantee is not eligible for a reward under this section if the information submitted came to his or her knowledge in the course of his or her official duties.
- An individual who illegally obtained the information he or she submitted is excluded from receiving a reward under this section.
- An individual who participated in the sanctionable offense with respect to which payment would be made is excluded from receiving a reward under this section.
Claiming the reward
Once fraud has been proven, funds have been recovered, and your eligibility has been proven, then you would receive a notification via mail to your most recent address. From there, you can start with the process of claiming your medicare fraud reward.
If you have relocated to an unknown place and did not receive the notification, you or your legal representative can claim the reward within one year. Keep in mind that the CMS does not pay interest on rewards not claimed immediately.
In worst cases where a whistleblower died or become incapacitated, then your legal representative may claim the reward on your behalf. They just need to prepare the following files such as:
- certified copies of the letters testamentary
- letters of administration
- other similar evidence to show his or her authority to claim the reward
Bear in mind that the reward needs to be claimed by your legal representative within 1 year from the date the CMS gave the notice for the award.
Healthcare fraud and abuse
Medicare fraud is a serious problem affecting both our healthcare workers and patients. It not only affects our healthcare financially but also paralyzes and does harm to the services that Medicare patients receive.
That being said, it is no wonder why the federal government has continued to invest in the Medicare fraud reward program. This not only helps identify undetected crime but also lightens the burden and pressure placed on the healthcare sector.
Reporting Medicare fraud
CMS and the Department of Justice highly encouraged everyone to report health care fraud or abuse. The Medicare fraud rewards are just a bonus to incentivize and protect anyone who wishes to come forward and report fraud.
To report a Medicare fraud, you can directly call the MEDICARE hotline or you can call the Medicare Drug Integrity Contractor if you are in a Medicare Advantage Plan.
As we have mentioned before, in order to be eligible to receive a reward, you need to submit the required information and follow other necessary protocols (depending on your state).
Generally, you can submit your tip or valuable information to the Office of the Inspector General, or to the Medicare intermediary or carrier that has jurisdiction over the suspected fraudulent medical provider or supplier. And for you to be eligible to receive an award, you need to provide
- name,
- address,
- telephone number, and
- any other requested identifying information so that he or she may be contacted, if necessary, for additional information and, when applicable, for the payment of a reward upon resolution of the case.
Protection for Medicare whistleblower
According to the Electronic Code of Federal Regulations, unless required by the law, the CMS would not reveal the whistleblower’s identity. This is mainly to protect and ensure the safety of the whistleblower.
Apart from that, there is also an anti-retaliation provision in the False Claims Act. It helps protect employees, contractors, or other agents of a company from being “discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of employment by his or her employer.”
So whether you are planning to report your boss or colleagues, the False Claims Act would protect you from being demoted, fired, and any other discriminatory practices that might happen in the workplace should you choose to be a whistleblower.
Once these conditions are violated, you are entitled to all relief necessary to make you a whole employee again. These types of relief can include:
- Reinstatement
- Double back pay
- Compensation for any damages
- Litigation costs
- Attorneys’ fee
Another noteworthy section in the False Claims Act is the Qui Tam provision. This provision enables whistleblowers like you to be eligible to receive a reward once fraud has been proven and funds have been successfully recovered.
The statute of limitation for filing a Qui Tam whistleblower are either
- Six years from the date of violation
- Three years after the government knows about the violation
Keep in mind that even though the Qui Tam Lawsuit is a provision in the False Claim Act, the statute of limitation in filing a Qui Tam recovery case is different from filing a False Claim Act retaliation case.
Another thing that you should look more into is the scope of these whistleblower protections from state to state. There are other states that provide other remedies or course of action to protect whistleblowers so we highly advised you to be familiar with your state law
Conclusion
All in all, medicare fraud rewards are not only beneficial to those who are receiving it, but it is also beneficial to our healthcare system.
To briefly recap, we have discussed several subjects surrounding medicare fraud rewards such as
- Nature of rewards
- Determining the amount and payment scheme of the reward
- Eligibility to receive rewards
- Claiming the reward
- Healthcare fraud and abuse
- Reporting Medicare fraud
- Protection for Medicare whistleblower
Bear in mind that the tips and topics mentioned above are not meant to be a comprehensive topic about medical fraud rewards nor should be construed as legal advice. We still highly suggest you consult and ask the advice of an experienced attorney from your state.