Fraud - what are my responsibilities and how would I handle this?

by Anonymous
(AZ, USA)

I have been working for a physician who is in a private practice for 8 months. I have started to see a pattern with several of his workers' compensation cases. The patient's seem to have more tests and procedures ordered than others with similar conditions. The physician asks me to complete and send a billing claim to the insurance carriers but its for a procedure that I don't think he has performed.
So what would be my responsibilities, and what should I do?

Thank you,
Anonymous (Name removed to protect identity)

Response:

My first thought when I ready your situation was to "get out of there!"

But seriously - I can’t really say "do this" or "do that" because these ethical dilemma's are are complicated sometimes if you don't know all the details. What I can say is what I would do in your situation from what you've explained.

The first thing is protect myself. What I mean by that is to make sure there is no way the biller (me) can be blamed for billing for procedures that were not performed - no charges entered or claims filed unless there is written documentation that the doctor said he performed the procedure(s).

If the doctor is verbally telling me to bill for charges - I can’t do that. When a biller knowingly and willingly participates in insurance fraud - they are guilty also.

Hopefully all the procedures he is telling you to bill for are documented - on something like a superbill or his patient encounter notes - evidence that shows he (says he) performed the procedure(s). In a situation like this it’s important to protect yourself and make sure there’s nothing the doctor can blame you for if he gets accused of fraud - or prosecuted. You are simply processing the procedures he performs.

Ultimately the doctor is morally and ethically responsible for the procedures he performs - or says are performed. We (the biller) are not in the exam room to know what the doctor did or didn’t do. But as a medical biller I feel I have an ethical obligation to report fragrant and obvious fraud when the temptation is to look the other way.


The dilemma is that if the biller reports this to the insurance carrier, they put their job in jeopardy. Of course if the doctor really is committing fraud it makes you wonder if you really want to work there - if you really want to work for someone with questionable ethics.

If you suspect fraud, most insurance companies have a way to submit suspected fraud via their website anonymously. There’s almost always a link on the home page of the web site. However they may request specific info such as dates of service, procedures, etc.

Fraud is serious and the physician could get in some serious legal trouble - and have to close the practice - which means you would be without a job. If the insurance auditors don’t find anything, he may feel betrayed and suspect the biller of turning him in.

If you notify (even anonymously) the insurance carrier(s), someone will eventually show up and start asking questions. When they do the doctor - given his ethics are already questionable - may very well start pointing fingers at others as the culprit. I imagine someone like this would do thi. And a likely target of blame is the one doing the billing. So even when you do the right thing - it can put you in a very vulnerable position.

If I was in such a situation, I would also be quietly looking for another job if possible because of what I mentioned above.

I don’t know if my rambling has helped you any but what I'm saying is just do the right thing - such that you have a clear conscience when you lay your head on the pillow at night - you don’t have any problem going to sleep.

There’s an old saying - "A righteous man (or woman) has nothing to fear."

Thanks and I hope this works out in your favor.