Healthcare Fraud Whistleblower Lawyers

Healthcare fraud happens when a person or company lies to get money from government-funded programs like Medicare, Medicaid, Tricare Veterans’ benefits. Because millions of Americans are insured by these programs, they handle huge amounts of taxpayer money. When they are targeted for fraud, a lot of money may be at stake.  

Three common types of healthcare fraud are: 

• Billing Fraud 

• Physician and Hospital Kickbacks 

• Pharmaceutical Fraud 

These fraudulent actions cost taxpayers billions of dollars each year and push healthcare costs higher for everyone. 

To fight this, the government uses the False Claims Act, a law that helps identify and prosecute the defrauding of government funds.  

Most major cases are uncovered by whistleblowers, people who witness and report the fraud. Even with these efforts, experts believe billions more in fraud still go unnoticed. 

Under the False Claims Act, whistleblowers who file a healthcare fraud qui tam lawsuit are protected from retaliation and job discrimination. If the lawsuit succeeds, they may receive up to 30% of the money the government recovers. 

According to the Department of Justice, health care fraud was one of the largest categories of whistleblower lawsuits in 2024. In 2024, whistleblowers helped recover over $1.67 billion from healthcare fraud cases, accounting for more than half of the $2.9 billion recovered under the False Claims Act. 

Overall, 979 qui tam lawsuits were filed across all industries in 2024, the highest number ever recorded. This highlights how whistleblowers play a key role in exposing fraud, especially in the health care system. 

Here are some examples of major healthcare fraud settlements and the rewards whistleblowers received: 

Johnson & Johnson – Pharmaceutical

• Settlement: $2.2 billion for promoting certain drugs for uses the FDA hadn’t approved and for paying illegal kickbacks to doctors and a large pharmacy. It’s one of the biggest healthcare fraud settlements in U.S. history, according to the Department of Justice.
• Whistleblower reward: $167.7 million divided among whistleblowers in Pennsylvania ($112 million), Massachusetts ($27.7 million) and California ($28 million). 

Novartis – Pharmaceutical

• Settlement: $370 million to settle claims that it gave kickbacks to specialty pharmacies in exchange for recommending two of its drugs, Exjade and Myfortic.
• Whistleblower reward: $66.4 million awarded to a former Novartis sales manager. 

Amedisys Inc. – Nursing and Therapy Services

• Settlement: $150 million to settle claims that it billed Medicare for nursing and therapy services that patients didn’t need or for patients who weren’t homebound, and misrepresented patients’ conditions to receive higher payments. 
• Whistleblower reward: $26 million split collectively among former Amedisys employees. 

Omnicare Inc. – Nursing Facility

• Settlement: $124.4 million for allegedly offering improper financial incentives to nursing facilities in return for their continued purchase of Omnicare to supply drugs to elderly Medicare and Medicaid patients. 
• Whistleblower reward: $17.24 million awarded to a former Omnicare employee. 

Adventist Health System – Hospital System

• Settlement: $115 million to settle allegations that it improperly compensated physicians for referring patients to its facility and miscoded claims sent to Medicaid and Medicare for reimbursement of physician services. 
• Whistleblower reward: The amount of the whistleblowers’ rewards in this case has not been released. Whistleblowers included a former risk manager, executive director of physician services and compliance officer.

The most common actions that lead to whistleblowing in medical billing are described below: 

• Upcoding fraud: Upcoding fraud occurs when a healthcare provider bills for a more serious, and more expensive, procedure than what the patient actually received. 

• Unbundling: Government healthcare programs often pay one rate for a group of procedures that are performed together. “Unbundling” fraud occurs when these procedures are billed separately. This results in the provider getting paid more than they should. 

• Lack of Medical Necessity: Government healthcare programs only pay for services, treatments, diagnostic tests, medical devices, and pharmaceuticals that are necessary. One common type of fraud happens when providers bill for things that are not medically necessary. 

• False Certification: When healthcare providers bill government healthcare programs, they must certify that the services were needed, actually performed, and followed all regulations. One common type of fraud involves falsifying these certifications to get paid or gain more business. 

• Inflating Overhead Cost: Medicare and other government healthcare programs reimburse hospitals not only for patient care, but also for some of their operating costs.To receive this money, hospitals must file Cost Reports that list their charges, revenue, profits, and charge-to-cost ratios.One common type of fraud involves hospitals inflating or falsifying information on these reports to get more reimbursement than they should. 

In the pharmaceutical industry, healthcare fraud typically arises through the illegal manufacture, promotion, and sale of drugs that are paid for by the government programs like Medicare, Medicaid, or Tricare. 

The most common pharmaceutical fraud cases include: 

• Making unsafe or poorly manufacturing drugs or avoiding manufacturing rules; 

• Lying to federal regulators about the safety or effectiveness of a drug; 

• Promoting drugs for uses that the FDA has not approved; 

• Providing financial incentives to doctors to prescribe certain drugs; and 

• Overcharging government healthcare programs for drugs. 

Whistleblowers can help stop this illegal activity by the pharmaceutical industry by filing a “qui tam” lawsuit under the False Claims Act. 

Kickbacks happen when doctors or hospitals are offered or receive money or gifts in exchange for referring patients or recommending certain healthcare services.  

These practices are illegal under federal laws like the Anti-Kickback Statute and the Stark Law, which exist to prevent healthcare fraud. 

Any offer, payment, or acceptance of these incentives in exchange for patient referrals can violate the law. 

 

Kickbacks can take many forms, including: 

• Referral fees or finder’s fees; 

• Bonuses tied to productivity  

• Discounts on equipment, leases, or rentals; 

• Research grants or speaker’s fees; 

• Excessive compensation; and 

• Free or discounted travel or entertainment. 

1. Medicare Fraud Whistleblowers
2. Pharmaceutical Fraud Whistleblowers
3. Billing Code Fraud: Upcoding/Unbundling
4. Pharmacy Whistleblowers
5. The Stark Law: Kickbacks to Providers