Medicare Fraud Whistleblower Attorneys

If you have original information about fraud against Medicare, Medicaid, or Tricare, you may be eligible for a reward of between 15 and 30 percent of what the government recovers under the False Claims Act.

Since 1988, the Medicare fraud whistleblower attorneys at Kohn, Kohn & Colapinto have guided insiders through every stage of the qui tam process — protecting their confidentiality, building the strongest possible case for government intervention, and maximizing their reward.

Medicare fraud occurs when healthcare providers — such as hospitals, physicians, pharmaceutical companies, nursing homes, hospice providers, laboratories, or medical equipment suppliers — knowingly submit false claims to government healthcare programs to obtain payments they are not entitled to receive. Because Medicare spending reached $1.1 trillion in 2024, according to the Centers for Medicare & Medicaid Services, the program is a constant target for fraudulent billing schemes. The National Health Care Anti-Fraud Association conservatively estimates that healthcare fraud costs the nation tens of billions of dollars each year — with some government estimates placing losses far higher.

Whistleblowers with inside knowledge are the government’s most effective tool for uncovering these schemes. Healthcare fraud remains the dominant source of False Claims Act recoveries: of the more than $6.8 billion the Department of Justice recovered in fiscal year 2025 — the highest single-year total in the history of the law — over $5.7 billion involved the healthcare industry, including fraud against Medicare, Medicaid, and TRICARE. Fiscal year 2025 also set a record for new qui tam lawsuits filed, at 1,297.

Medicare fraud takes many forms. Whistleblowers who recognize these schemes are often the only people positioned to expose them:

• Billing for services not rendered — also known as phantom billing, where providers submit claims for procedures, tests, or visits that never occurred.
• Upcoding — billing for more complex or expensive services than were actually provided by submitting inflated CPT codes.
• Unbundling — separately billing services that should be billed together under a single code to increase reimbursement.
• Kickbacks — offering or accepting anything of value in exchange for patient referrals or business involving services covered by Medicare, Medicaid, or Tricare, in violation of the Anti-Kickback Statute.
• Risk-adjustment fraud — manipulating patient diagnosis codes in Medicare Advantage (Part C) plans to make patients appear sicker than they are, inflating payments from CMS.
• Medically unnecessary services — performing and billing for procedures, tests, or equipment that patients do not need.
• Durable medical equipment (DME) fraud — billing for wheelchairs, braces, or other equipment that was never delivered or never needed.
• Hospice and nursing home fraud — enrolling patients who are not terminally ill in hospice care, or billing for a higher level of care than is provided.
• Prescription drug fraud — including illegal off-label marketing, pharmacy billing schemes, and drug-switching.
• Telehealth fraud — billing for remote consultations that never occurred or were medically unnecessary.

The False Claims Act (31 U.S.C. §§ 3729–3733) is the government’s primary weapon against fraud in federal healthcare programs. Enacted by Congress in 1863 and signed into law by President Abraham Lincoln to combat fraud by defense contractors during the Civil War, the law today allows private citizens — known as qui tam relators — to file lawsuits on behalf of the United States against those who defraud government programs.

Violators of the False Claims Act are liable for three times the amount of the government’s losses, plus a civil penalty for each false claim. The penalties are adjusted for inflation: for penalties assessed after July 3, 2025, the minimum is $14,308 and the maximum is $28,619 per claim (28 C.F.R. § 85.5). Because large healthcare fraud schemes can involve thousands of individual false claims, total liability often reaches into the tens or hundreds of millions of dollars.

Whistleblowers who report Medicare or Medicaid fraud under the False Claims Act are eligible for substantial financial rewards. If the government intervenes in the case and recovers funds, the whistleblower is entitled to between 15 and 25 percent of the total recovery. If the government declines to intervene and the whistleblower proceeds with the case, the reward rises to between 25 and 30 percent. A successful whistleblower is also entitled to reasonable attorneys’ fees and costs.

Merely reporting the fraud to the government is not enough to qualify — a reward is paid only if, and after, the government recovers money as a result of a qui tam lawsuit. To learn more about eligibility, award determination, and the reporting process, read our guide to Medicare fraud rewards.

Reporting Medicare fraud under the False Claims Act follows a defined legal process:

1. Consult a whistleblower attorney. A qui tam lawsuit cannot be filed pro se — the law requires the relator to be represented by counsel, and the strength of the initial filing often determines whether the government intervenes.
2. Gather evidence. Document the fraud with billing records, internal communications, compliance reports, or other materials that establish what happened, who was involved, and how the government was harmed.
3. File the complaint under seal. The lawsuit is filed confidentially in federal court and served on the government — not the defendant. While the case is under seal, your identity is not publicly disclosed.
4. Government investigation. The Department of Justice, often working with the HHS Office of Inspector General, investigates the allegations. The seal period lasts at least 60 days, but is frequently extended.
5. Intervention decision. The government decides whether to intervene and take over the case, or decline, in which case the whistleblower may proceed on the government’s behalf.
6. Litigation or settlement. Most successful qui tam cases resolve through settlement; others proceed to judgment.
7. Award determination. If the case succeeds, the court and the government determine the relator’s share — 15 to 30 percent of the recovery — based on the significance of the information and the whistleblower’s contribution to the case.

Medicare and Medicaid cases are challenging, and the government requires strong evidence before it will pursue a case. Employees and insiders who have worked within the organization they are reporting have the best chance of success. Whistleblowers with direct knowledge of a specific fraudulent scheme — and documentation to support it — have a significant advantage, which increases both the likelihood of government intervention and the size of any eventual award.

The False Claims Act protects whistleblowers from retaliation. Under 31 U.S.C. § 3730(h), an employee who is fired, demoted, suspended, threatened, harassed, or otherwise discriminated against for lawful whistleblowing is entitled to relief including reinstatement, double back pay plus interest, and compensation for special damages, including litigation costs and attorneys’ fees.

Kohn, Kohn & Colapinto has represented whistleblowers in some of the most significant healthcare fraud cases brought under the False Claims Act:

Bristol-Myers Squibb — $515 million recovery. KKC represented whistleblower Daniel Richardson, a former BMS sales representative who filed a qui tam lawsuit alleging the company illegally marketed drugs and paid kickbacks to physicians, driving up costs to Medicare, Medicaid, Tricare, and other government healthcare programs. The government recovered over $515 million, and Mr. Richardson received the largest individual relator share among the whistleblowers who worked for the company.

Novartis — more than $300 million in sanctions. Our firm represented a whistleblower in a case against Novartis involving illegal drug marketing and bribes. The company paid over $300 million in sanctions and fines. The whistleblower remains anonymous, and the award amounts are confidential.

For over 35 years, our attorneys have shaped the modern law of whistleblowing. Our partners helped found the National Whistleblower Center in 1988, have testified before Congress on the False Claims Act and qui tam rewards, and have written the leading books on whistleblower law, including Rules for Whistleblowers: A Handbook for Doing What’s Right (2023). We obtained the largest reward ever paid to an individual whistleblower, and our record in Medicare and healthcare fraud cases speaks for itself. When whistleblowers go up against the world’s most powerful healthcare companies, they come to us.