Practice Areas

Medicare Fraud

Medicare fraud costs the federal government billions of dollars each year. If you work in healthcare and have witnessed false billing, upcoding, or other schemes against Medicare, you may have the basis for a qui tam case. Reach out for a confidential conversation. There is no obligation.

Practice Areas

Medicare Fraud

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WHAT IS MEDICARE FRAUD?

Medicare fraud occurs when healthcare providers, organizations, or individuals submit false or fraudulent claims to Medicare for services that were not provided, were not medically necessary, or were misrepresented to obtain a higher reimbursement than what was actually owed. Medicare is a federal health insurance program administered by the Centers for Medicare and Medicaid Services (CMS), and claims submitted to it are claims against the United States government.

Because Medicare fraud constitutes the submission of false claims to the federal government, it falls squarely within the scope of the False Claims Act. Healthcare insiders who have direct, first-hand knowledge of Medicare fraud may be eligible to file a qui tam lawsuit on behalf of the government and receive a share of any financial recovery.

In fiscal year 2025, the Department of Justice’s 2025 National Health Care Fraud Takedown resulted in criminal charges against 324 defendants in 50 federal districts for alleged participation in healthcare fraud schemes involving over $14.6 billion in intended loss.

More than $5.7 billion of the $6.8 billion recovered through False Claims Act enforcement in fiscal year 2025 came from healthcare-related fraud matters, including Medicare fraud.

Source: U.S. Department of Justice, FCA Statistics FY 2025, January 2026 | justice.gov

Legal basis: 31 U.S.C. § 3729 (False Claims Act) | 42 U.S.C. § 1395 et seq. (Medicare) | Source: uscode.house.gov

TYPES OF MEDICARE FRAUD THIS PRACTICE HANDLES

Medicare fraud schemes vary in complexity. The following are the most common types handled by this practice.

Medicare Billing Fraud: Billing Medicare for services that were never performed, or for a quantity of services that exceeds what was actually provided. This includes billing for patients who were never seen, billing for services ordered but not rendered, and billing for equipment that was never delivered.

Medicare Advantage Fraud: Medicare Advantage plans receive payments from the federal government based on the health risk profile of their enrolled patients. Fraud in this area typically involves submitting false or unsupported diagnosis codes to inflate risk adjustment payments. In fiscal year 2025, Seoul Medical Group Inc. agreed to pay over $60 million to resolve allegations that it caused the submission of false diagnosis codes for spinal conditions that patients did not have in order to increase payments from the Medicare Advantage program.

Upcoding: Billing Medicare for a more expensive service or procedure code than was actually provided. For example, billing for a complex office visit when only a brief consultation took place, or coding a routine surgical procedure under a higher-reimbursement code.

Unbundling: Billing Medicare separately for individual components of a procedure that Medicare requires to be billed together under a single code. Providers who unbundle services receive a higher combined reimbursement than they would under the correct bundled billing code.

Phantom Billing: Submitting claims to Medicare for services, visits, or equipment that were never provided to the patient at all. This includes billing for deceased patients, billing for patients who were in a hospital or other facility on the date of the claimed service, and billing for services that exist only on paper.

WHO CAN REPORT MEDICARE FRAUD?

The strongest Medicare fraud qui tam cases come from people with direct, first-hand knowledge of the fraud from inside a healthcare organization. This includes current and former employees in roles such as billing specialists and medical coders, nurses and clinical staff, physicians, office administrators, compliance officers, home health aides, and hospital or clinic employees with access to billing records.

You do not need to have all the documents or a complete picture of the scheme before reaching out. If you have witnessed conduct that you believe constitutes false billing to Medicare, that is enough to start a confidential conversation. We investigate thoroughly before asking for any commitment, and we will give you an honest assessment of whether your case is viable.

Former employees also have standing to file qui tam cases, provided the complaint is filed within the applicable statute of limitations under the False Claims Act. In fact, many former employees come forward with knowledge of fraudulent practices by their former employers after they have been demoted or terminated for complaining to their supervisors about the fraudulent practices or leaving their employment because they refuse to participate in the fraud.

Legal basis: 31 U.S.C. § 3730(b) (qui tam provisions) | Source: uscode.house.gov

YOUR PROTECTIONS AS A WHISTLEBLOWER

The False Claims Act prohibits your employer from firing, demoting, suspending, harassing, or otherwise retaliating against you for reporting Medicare fraud or participating in a qui tam case. These anti-retaliation protections apply to both current and former employees.

When you file a qui tam complaint, it is submitted under seal. Your employer is not notified and does not receive a copy of the complaint. Your identity remains protected throughout the government’s investigation.

If your employer retaliates against you, you have legal remedies that include reinstatement, two times the amount of back pay owed, interest on that back pay, and compensation for special damages including litigation costs and attorney fees.

Legal basis: 31 U.S.C. § 3730(h) (anti-retaliation) | 31 U.S.C. § 3730(b) (under seal filing) | Source: uscode.house.gov

WHISTLEBLOWER REWARDS

When a qui tam lawsuit results in a financial recovery, the False Claims Act entitles the relator to receive a percentage of the total amount recovered by the government. If the government intervenes and takes over the case, the relator receives between 15% and 25% of the recovery. If the government declines to intervene and the relator proceeds independently, the share rises to between 25% and 30%. There is no cap on the dollar amount of the reward. We work on a contingency fee basis. There is no upfront cost, and if there is no recovery, you owe us nothing.

Legal basis: 31 U.S.C. § 3730(d)(1) and § 3730(d)(2) | Source: uscode.house.gov

About This Practice

Arvind Bob Khurana has over 27 years of experience in qui tam and False Claims Act litigation, complex commercial litigation, and class action matters. He began his career at a top international defense firm and joined a national class action firm in 2005, becoming partner in 2009, where he worked on ERISA actions, qui tam cases, securities fraud, and antitrust matters. He is admitted to the New York State Bar and represents whistleblowers in federal courts nationwide.

We are selective. Before we ask for any commitment, we investigate the claim, explain the facts and the risks, and give you a complete picture of what you are facing. We never ask you to sign a retainer agreement until you have the full picture and have decided, on your own terms, that you want to move forward. You remain in control throughout.

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Arvind Bob Khurana has over 27 years of experience in complex litigation. We work on contingency. There is no upfront cost. No obligation to proceed.