Marking one of the most aggressive actions against Medicare Advantage fraud, the Department of Justice recently (May 2025) intervened and unsealed a civil complaint that reveals a vast Medicare kickback scheme that prioritized company profits over subscriber needs. The case, originally filed under the false claims act by a former eHealth employee (whistleblower), alleges that a group of insurers paid hundreds of millions of dollars (kickbacks) to incentivize brokers to steer enrollments into their plans regardless of their suitability to the member. A particularly damning aspect of the case involves two of the insurers conspiring with brokers to discriminate against disabled enrollees perceived as less profitable, in violation of the ADA and Medicare Advantage anti-discrimination rules. Not only were ethical standards allegedly breached, but the MA enrollment certifications false, justifying False Claims Act penalties. The case is just heating up, with potential damages into the billions. The whistle blower could receive 15 to 30 percent of the recoveries.
Qui tam lawsuits allow private individuals (whistleblowers or “relators”) to sue on behalf of the government for fraud against federal programs. A qui tam lawsuit is a legal action filed under the False Claims Act (FCA) where a whistleblower sues a person or entity for defrauding the government in programs such as Medicare, Medicaid, or federal contracts. Consequently, the whistleblower, often an employee, former employee, contractor or insider privy to fraudulent activities, may be awarded a portion of recovered funds.
Common qui tam cases include billing the government for services or goods not provided; overcharges for products and services; submitting false certifications for compliance with federal regulations; and fraud in healthcare (e.g., Medicare/Medicaid fraud), defense contracts, or government grants.
What is the False Claims Act (FCA)?
The False Claims Act is a federal law that imposes liability on individuals or entities who defraud government programs. It allows whistleblowers to file qui tam lawsuits and provides protections against retaliation for reporting fraud.
- Although most qui tam cases involve federal programs under the FCA, many states also have their own false claims laws, allowing whistleblowers to file qui tam suits for fraud against state governments (e.g., Medicaid fraud in state programs).
After investigating a qui tam case, the government may intervene based on the evidence’s strength, the case’s complexity, and potential recovery. The government intervenes in about 20–25% of cases. A whistleblower typically receives 15–25% of recovered amounts if the government intervenes, or 25–30% if the whistleblower and their attorney pursue the case independently without government intervention.
Protections for Whistleblowers
Whistleblowers work with a qui tam attorney to file a claim. The name of the whistleblower is disclosed to the court and government, but the case is filed under seal, keeping the identity of the whistleblower confidential initially, with public disclosure occurring if the case proceeds. Whistleblowers are protected against retaliation (e.g., firing, demotion, or harassment) for reporting fraud and may seek remedies including reinstatement, back pay, and other damages if they are subject to retaliation under the FCA.
Whistleblower First to File Rule
Because there may be more than one individual privy to fraud, the FCA first-to-file rule bars multiple whistleblowers from filing separate qui tam lawsuits based on the same fraud. The first whistleblower to file with original information typically has priority, and will reap the rewards of a successful case accordingly. It is important to note that whistleblowers need specific, non-public evidence of fraud, such as documents, emails, or firsthand knowledge of false claims submitted to the government. Strong evidence increases the likelihood of government intervention and success.
Contact an Experienced Qui Tam Lawsuit Attorney for Help
When you are or someone you know has evidence that their employer or other entity has committed fraud, it is important to discuss your concerns with an experienced qui tam attorney. Look for an attorney experienced in FCA or whistleblower law, who can advise you on the strength of your case and skillfully represent you throughout the process. Contact the qui tam lawyers of Alan C. Olson & Associates for immediate assistance at 262-785-9606.
