Medicare and Medicaid Fraud and the Heroes Exposing It

Updated on July 4, 2024

Medicare and Medicaid provide essential healthcare services to elderly and low-income individuals. The necessary programs involve over one trillion dollars of federal funds each year nationwide. In addition to vast amounts of money, the sheer size of these programs makes monitoring very difficult. As a result, we must count on “whistleblowers” to report any fraud or abuse in Medicare or Medicaid programs.

Types of Medicare or Medicaid Fraud

Medicare and Medicaid fraud take various forms. One common trait each fraudulent act shares is the desire to exploit the government for financial gain. In other words, the perpetrators want to make money. Some common types of Medicare or Medicaid fraud include:

Billing for services not rendered

Billing for services not rendered is a fraudulent practice where healthcare providers charge Medicare or Medicaid for treatments and procedures that were never performed. For example, a physical therapy practice might only provide massage therapy to patients. However, the therapist bills Medicare for additional services such as ultrasound, traction, electrotherapy, ice, and heat. Each of these services has a specific code and associated cost. By billing for these unprovided services, the therapist receives higher payments than warranted, resulting in substantial financial gain. This practice not only defrauds the government but also undermines trust in the healthcare system. Patients do not receive the treatments for which the government is billed, leading to a misuse of federal funds intended for legitimate medical care. 


Upcoding is a deceptive practice where healthcare providers intentionally assign a higher billing code to a service or procedure than what was actually performed. This illegal act is done to obtain higher reimbursement from Medicare or Medicaid. By misrepresenting the provided services, providers can fraudulently increase their payments, undermining the integrity of the healthcare system and diverting essential funds away from legitimate medical needs.

Unnecessary procedures

Billing for unnecessary medical procedures is considered a form of Medicare and Medicaid fraud. This fraudulent activity involves healthcare providers performing and billing for medical procedures that are not medically necessary, solely to increase their reimbursement from these government programs. Such practices not only waste valuable resources but also subject patients to potential harm from unnecessary medical interventions. This type of fraud is especially concerning for vulnerable populations, such as the elderly, who may not have family members overseeing their care and advocating on their behalf.

Healthcare employees who observe unnecessary procedures being performed and billed should take action. It is their ethical duty to contact a healthcare fraud attorney and report these practices to prevent further exploitation and potential harm to patients. Reporting such fraud helps protect the integrity of the healthcare system, ensures that federal funds are used appropriately, and upholds the trust placed in medical professionals. By stepping forward, whistleblowers play a crucial role in safeguarding patient welfare and maintaining ethical standards in healthcare.

False documentation

False documentation involves billing for procedures never performed or for patients who were never seen at the practice. This can take various forms, such as billing for fictitious medical treatments, diagnostic tests, or consultations that did not occur. Additionally, billing for home health care visits that never took place is a blatant act of fraud. This type of misconduct not only defrauds the government but also undermines the trust in the healthcare system. Once again, employees who witness or suspect false documentation should seek legal guidance to protect themselves and help expose the fraudulent activities. Reporting such practices is crucial in maintaining the integrity of healthcare services and ensuring that federal funds are used appropriately.

Penalties for Committing Fraud

The penalties for Medicare or Medicaid fraud may be quite severe. Civil or criminal charges are filed depending on the severity of fraud. Healthcare providers found guilty of Medicare or Medicaid fraud may face substantial fines or imprisonment.  Also, the provider may be excluded from participating in any government healthcare program in the future. Finally, the guilty party may face civil lawsuits brought by the government or whistleblowers seeking damages.

Legal Protections for Whistleblowers

Federal and State governments recognize the importance of healthcare whistleblowers. A whistleblower is a person who sees illegal activity happening at work and reports it. Reporting on fellow employees takes great courage. In fact, many people remain afraid to “snitch” on others. They fear demotion, harassment, termination, or other actions. Thankfully, The False Claims Act prohibits retaliation against whistleblowers. Other laws, such as the Whistleblower Protection Act also offer protection to employees who report fraud. To sum up, contact an experienced attorney if you are considering the role of whistleblower.

Rewards for Whistleblowers

Whistleblowers play a vital role in exposing Medicare and Medicaid fraud. Individuals with knowledge of fraud against the government are allowed to file lawsuits on behalf of the government. It is vital to use an experienced attorney to file this type of lawsuit. An individual that chooses to file this type of lawsuit is known as qui tam relators. With your attorney’s assistance, if you win this lawsuit you are entitled to up to 30% of recovered claims. However, if the government intervenes and becomes part of the case, you may be entitled to some compensation. Of course, another point to consider is how do you know this illegal activity is happening?  Has your employer forced you to be involved in any way? Considering these questions, if you know that Medicare or Medicaid fraud is happening where you work, contact an attorney immediately. 

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The Editorial Team at Healthcare Business Today is made up of skilled healthcare writers and experts, led by our managing editor, Daniel Casciato, who has over 25 years of experience in healthcare writing. Since 1998, we have produced compelling and informative content for numerous publications, establishing ourselves as a trusted resource for health and wellness information. We offer readers access to fresh health, medicine, science, and technology developments and the latest in patient news, emphasizing how these developments affect our lives.