Healthcare fraud takes a toll on patients, taxpayers, and public programs like Medicare and Medicaid. In Georgia, it can also affect state-run systems such as PeachCare for Kids® and the State Health Benefit Plan. If you’ve witnessed suspicious billing, unnecessary testing, or illegal kickbacks, it’s natural to wonder how and where to report healthcare fraud.
Before reporting anything to a government hotline, talk to a lawyer. You may be entitled to a financial reward under the federal False Claims Act, and under Georgia’s Medicaid False Claims Act for fraud involving state healthcare programs. But that opportunity exists only if your report is filed the right way. A Georgia healthcare fraud lawyer at Griffin Durham Tanner & Clarkson can guide you through the legal process and protect your rights every step of the way.
What counts as health care fraud?
The Office of Inspector General defines health care fraud as any deliberate act to mislead or deceive a healthcare program for unauthorized financial gain. These schemes can involve providers, patients, vendors, or third parties.
Under federal law, several statutes govern and prohibit fraudulent conduct in connection with Medicare, Medicaid, and other health programs, including the False Claims Act (FCA), the Anti-Kickback Statute (AKS), and the Physician Self-Referral Law (Stark Law).
These laws are enforced by agencies like the Department of Justice, HHS OIG, and the Centers for Medicare & Medicaid Services (CMS), and violations can result in civil fines, criminal penalties, or exclusion from federal health programs.
Some of the most common schemes include:
- Phantom billing: Billing for visits or services that never occurred
- Identity theft: Using another person’s insurance without permission
- Prescription diversion: Selling or distributing prescription drugs illegally
- False documentation: Falsifying patient records or treatment notes to justify billing
- Telehealth abuse: Submitting fraudulent telemedicine claims or incentivizing remote practitioners to order excessive testing without patient contact
- Doctor shopping: Going to multiple clinics for duplicate prescriptions
- Medically unnecessary services: Prescribing or billing for unneeded equipment or treatments, like repetitive diagnostic tests
- Upcoding procedures: Billing for more complex or expensive procedures than were actually performed, such as coding acupuncture as neurostimulator implantation
- Kickbacks and referral schemes: Paying or receiving compensation for patient referrals or test orders, especially in telemedicine or genetic testing contexts
- Facility-enabled fraud: When hospitals or clinics profit from enabling physician misconduct, including billing for procedures not performed or performed by someone else
To protect yourself from becoming involved, intentionally or not, keep an eye on billing practices, avoid blanket protocols that drive unnecessary care, and report any concerns through trusted legal or regulatory channels. If you’ve seen any of these red flags, speak with a healthcare fraud attorney to determine whether you may qualify for whistleblower protections.
Why you should speak with a lawyer before reporting fraud
If you suspect health care fraud in Georgia, don’t rush to submit a report to the government. While agencies like the Georgia Office of Inspector General or State Health Benefit Plan Fraud Unit accept reports, submitting one on your own can limit your legal options or prevent you from recovering a whistleblower reward.
A False Claims Act attorney can help you:
- Determine whether the conduct qualifies as fraud
- Preserve your eligibility for financial compensation
- Protect your confidentiality and employment rights
- Prepare and submit a whistleblower claim securely and strategically
Once a report is made directly to the government, it may be too late to pursue a qui tam lawsuit. That’s why it’s important to speak to a qualified attorney before you act. Speaking to an FCA attorney is confidential, and in many cases, whistleblowers can remain anonymous throughout the investigation.
What happens after you report fraud?
After receiving a report, the Office of Inspector General evaluates the claim and decides whether to investigate through its Program Integrity Unit, Audit Office, or Special Investigations Unit.
After the review stage, the findings may be shared with the Attorney General’s Office, the DCH Commissioner, or any other relevant parties. But once a case is open, there are no updates until it’s officially closed. This protocol is consistent across both state and federal agencies.
If the alleged conduct involves Medicare or Medicaid fraud, the case may be escalated to federal agencies such as HHS or the DOJ. These agencies collaborate with state authorities and insurance partners to pursue enforcement.
Once a report is submitted, the government, not you, controls the investigation. You may not receive updates, and your right to file a separate civil claim could be lost. That’s why it’s so important to consult an attorney first. We can help you report fraud while preserving your legal interests and potential reward eligibility.
Don’t report to federal agencies without legal advice
Federal agencies like the Department of Health and Human Services (HHS) and the FBI accept fraud reports, but that doesn’t mean it’s your best first step. Reporting fraud directly may:
- Waive your eligibility for whistleblower compensation
- Trigger an investigation without protecting your legal rights
- Expose you to potential retaliation without legal safeguards
Before taking action, speak with a Georgia False Claims Act lawyer. Our team at Griffin Durham Tanner & Clarkson helps whistleblowers file secure, legally sound reports that preserve your rights and position you for reward eligibility under federal law.
What if you’re being investigated?
You don’t have to blow the whistle to become part of a fraud investigation. If you’ve been contacted by the Office of Inspector General or served with a subpoena, your role may already be under scrutiny.
People who work in billing, coding, compliance, telehealth, or as healthcare providers can get caught up in investigations, even if they didn’t knowingly do anything wrong. These cases can lead to serious consequences, like fines, criminal charges, loss of a license, or damage to your reputation.
Don’t respond to investigators without legal guidance. Early legal representation can clarify your role and protect your rights during interviews or document production.
If you’re concerned about retaliation for speaking up, you should know that the False Claims Act includes anti-retaliation protections. These protections can apply if you’ve been demoted, harassed, fired, or otherwise penalized for trying to stop fraud or report it internally or externally.
Use your voice wisely and protect your future
Under the False Claims Act, whistleblowers may receive between 15% and 30% of the amount the government recovers. But that opportunity is only available if the report is filed correctly.
At Griffin Durham Tanner & Clarkson LLC, we help whistleblowers and professionals navigate healthcare fraud cases with discretion and strategy. If you’re ready to report or worried you’re being targeted, our Georgia attorneys are here to guide you. Contact us online, call our Atlanta office at (404) 891-9150, or get in touch with our Savannah office at (912) 867-9140.