Fraud Type Guide
Healthcare Fraud
Medicare and Medicaid fraud costs U.S. taxpayers an estimated $60–90 billion per year. If you witnessed billing fraud, kickbacks, hospice abuse, or false certifications, federal law gives you the right to report it — and potentially earn a reward of 15–30% of what the government recovers.
$60–90B
Estimated annual Medicare/Medicaid fraud
15–30%
Reward range under the False Claims Act
$75B+
Recovered under the FCA since 1986
What Qualifies
Common healthcare fraud schemes
Any of these schemes — when they involve federal healthcare programs — may qualify for whistleblower protection and reward eligibility.
Medicare & Medicaid Billing Fraud
Providers billing for services never rendered, billing for a higher-cost service than delivered (upcoding), or billing for medically unnecessary procedures. This is the single largest category of federal healthcare fraud by dollar volume.
- Phantom patient visits
- Upcoded procedure codes
- Duplicate billing
- Unbundling of services
Hospice & Home Health Fraud
Enrolling patients who do not qualify for hospice or home health benefits, billing for care not provided, or paying illegal kickbacks to physicians for referrals. The White House Task Force suspended over 470 providers in Los Angeles alone in 2026.
- Non-terminal patients enrolled in hospice
- Kickbacks to referring physicians
- Billing for absent nurses or aides
- Falsified eligibility certifications
Pharmaceutical & Device Kickbacks
Drug manufacturers or medical device companies paying physicians, hospitals, or pharmacies to prescribe or recommend their products — a violation of the Anti-Kickback Statute and the False Claims Act.
- Speaker fees as disguised kickbacks
- Free samples converted to billed claims
- Off-label promotion tied to Medicare billing
- Consulting agreements with no real services
Medicaid Provider Fraud
State Medicaid programs are jointly funded by federal and state governments, making fraud a federal matter. Common schemes include billing for ineligible beneficiaries, falsifying credentials, and operating without required licenses.
- Billing under a deceased provider's NPI
- Unlicensed facilities billing as licensed
- Childcare subsidy fraud (CCDF)
- Autism and behavioral health billing fraud
Applicable Programs
Which programs cover healthcare fraud?
Multiple federal programs may apply to the same scheme. The False Claims Act is the primary vehicle for reward-eligible reporting.
False Claims Act
15–30% rewardThe primary tool for healthcare fraud. Covers any false claim submitted to Medicare, Medicaid, or any federal health program. Qui tam relators can file under seal and receive 15–30% of government recovery.
Threshold: No minimum — DOJ focuses on cases with substantial federal losses
HHS Office of Inspector General
Discretionary rewardHHS-OIG investigates Medicare and Medicaid fraud, abuse, and waste. Reports can trigger audits, exclusions, and criminal referrals. No statutory reward, but tips directly inform enforcement.
Threshold: Any credible allegation of Medicare/Medicaid fraud
IRS Whistleblower Program
15–30% rewardApplies when healthcare fraud also involves tax violations — such as providers failing to report income from fraudulent billings, or offshore accounts funded by fraud proceeds.
Threshold: $2M+ in disputed taxes, penalties, and interest
Reporting Process
How to report healthcare fraud
Document what you know
Gather specific details: provider names, NPI numbers, billing codes, dates of service, and the gap between what was billed and what was actually delivered. Internal records, emails, or billing printouts are valuable.
Consult a whistleblower attorney
False Claims Act qui tam cases must be filed by an attorney. Most whistleblower attorneys work on contingency. An attorney can assess whether your information is already known to the government (which affects reward eligibility).
File under seal
FCA complaints are filed in federal district court under seal, meaning the defendant is not notified. The DOJ has 60 days (often extended) to investigate before deciding whether to intervene.
Cooperate with investigators
If DOJ intervenes, they take the lead. If they decline, you can proceed independently. Either way, your cooperation and the quality of your evidence directly affect the outcome and your reward.
Important disclaimer
Fraud Report is a private platform and is not affiliated with the U.S. government, HHS, CMS, or DOJ. Submitting a report here does not constitute a formal agency filing, does not establish reward eligibility, and does not trigger statutory whistleblower protections. To file an official False Claims Act qui tam complaint, you must retain a licensed attorney and file in federal court.
Official reporting resources
Explore other fraud types
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