How Do I Report Healthcare Fraud and Protect Myself as a Whistleblower, in Oregon?

Understanding Qui Tam Cases Under the False Claims Act: A Whistleblower's Guide

Fraud against the government, particularly within the healthcare sector, costs taxpayers billions of dollars each year. To combat this, the False Claims Act (FCA) includes powerful qui tam provisions, allowing individuals with insider knowledge of fraudulent activities to step forward as whistleblowers. For those working in healthcare—whether as medical assistants, office administrators, or even partners at clinics—understanding these provisions can be a crucial first step toward exposing misconduct and protecting public funds.

What Is a Qui Tam Case?

Under the FCA, a qui tam lawsuit enables a private individual, known as a relator, to file a claim on behalf of the U.S. government against entities committing fraud. Common types of healthcare fraud under the FCA include:

• Billing for services not provided or medically unnecessary procedures
• Improper coding or upcoding to increase reimbursements
• Violations of federal regulations, such as anti-kickback laws or Stark Law
• Failing to meet quality-of-care standards

Relators may earn between 15% to 30% of the recovered funds, depending on whether the government intervenes in the case.

Why Healthcare Employees Are Key Whistleblowers

Healthcare workers are often the first to notice irregularities in billing, compliance, or patient care. Medical office staff might observe improper coding practices, while clinicians may encounter unnecessary procedures being ordered to inflate claims. Even partners or shareholders in a medical practice might discover fraudulent billing practices that expose the organization to FCA liability.

In fact, healthcare fraud accounts for the majority of qui tam cases, with private individuals filing over 90% of these lawsuits. This trend highlights the vital role that insiders play in identifying fraud that might otherwise go unnoticed.

How the Process Works

Filing a qui tam lawsuit involves several critical steps:

1. Confidential Filing: The lawsuit is filed under seal, ensuring the government has an opportunity to investigate before the case becomes public.
2. Government Intervention: The Department of Justice may decide to take over the case. While this reduces the relator’s potential share of the recovery, it significantly increases the likelihood of success.
3. Proceeding Without Intervention: If the government declines, the relator may continue the lawsuit independently with legal counsel.

Regardless of the path, whistleblowers play a vital role in holding wrongdoers accountable and protecting public healthcare funds.

Legal Protections for Whistleblowers

Whistleblowers are often concerned about potential retaliation. Fortunately, the FCA includes whistleblower protection provisions, safeguarding employees from wrongful termination, demotion, or harassment. Those who face retaliation may be entitled to reinstatement, back pay, and compensation for damages.

Why Legal Representation Matters

The complexities of FCA litigation make experienced legal counsel essential. A knowledgeable attorney can guide whistleblowers through filing requirements, protect their rights, and maximize potential recoveries. Moreover, an attorney ensures compliance with the FCA’s “original source” rule, which requires relators to have direct, independent knowledge of the fraud. 

Grant Engrav is the founding partner of ELO (engravlawoffice.com), general counsel for the Oregon Ambulatory Surgery Association, and has served on the Executive Committee for the Health Law Section of the Oregon State Bar.   Please reach out to [email protected] to schedule a no-charge initial consultation with Grant Engrav.