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. They will eventually get caught.



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.

If Medicare is involved than the provider should be reported by calling the Office of Inspector General (OIG) Hotline at 1-800-HHS-TIPS (1-800-447-8477). You can report a complaint anonymously, but it does make it more difficult for the OIG to investigate. The civil and criminal penalties for Medicare fraud can be pretty severe for the offenders.

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 this kind of thing. 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.

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

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Jun 08, 2014
UMA Student
by: Anonymous

I am currently a UMA student doing the same assignment. I found it quite interesting that many are trying to research the answer to this question. Well I have great news for you, the answer is in the IHMO book. You have already learned about fraud, the responsibility of a medical biller, ethical behavior, moral values, policies and procedures, standard precautions, and state and federal laws. I feel this assignment was to refresh your memory and give your input on the subject. I hope everyone is thoroughly reading this book and not just highlighting the subjects on the study guide. This will not help you if you don't have retention. Please pay attention to the assignment before researching the internet. Your book holds a lot of valuable information.

Dec 15, 2013
UMA student
by: Anonymous

I find it so interesting that most of us are from UMA. As a student here i find that i'm not the only one that needs help and i tend to search online to get answers and then try to form them on my own. The book doesn't always tell you everything so they said it's ok to use the internet but to just make sure that you cite your sources. I don't even know about this school anymore, It's making me wonder. smh. We all know about fraud and what we need to do to protect ourselves being that any doctor could be quick to turn the problem to the biller, but we have to do whats right.

Oct 27, 2013
Workers comp fraud
by: Anonymous

Yes , I am a student as well and this piece had a wealth of information. However, I will not be using this as my source. I like to remain honest in my writing assignments, you are only cheating yourself out of a wonderful educational learning experience. If you take the time to research, you will find many states have their own particular outlines of how you go about reporting a physician who is participating in workers compensation fraud. Simply search the state that you currently reside in and see what steps they recommend for reporting workers comp fraud by a physician.

Jun 19, 2013
Critcizing
by: Anonymous

I like showing others that like to criticize someone else for doing the exact same thing they are doing. You should share you view on this question, its nice to have opposing views of a situation no matter if its not by the book. Anyone can plug in a question from school, like I did to research what others may have posted and since there is no discussion on the topic its hard to base how you would do something in this situation off a question and you have never been in the environment yet. If you are a UMA student you should already know what judgment is by now since you are also taking a TBLS assignment. Next time don't think so horrible about the situation and leave your point of view.

Me myself I would check the patients WC file to make sure it is corresponds with what I am billing the insurance. If it doesn't then I would approach the doctor.

Jun 19, 2013
To funny
by: Anonymous

I plugged in the question as well, since I am in UMA and this info came up. People are really cut throat on here. Its not rocket science that you should question your doctor, look at corresponding info to find out if the claim is false, esp. if the procedure isn't written in the clients WC file. seriously people take a chill pill, most people in UMA haven't been to school in years and have lack there of search engine skills. But it is nice since its a new subject to have other views on the topic. So if you have a view you should share otherwise you should criticize another for doing the same thing you are doing as well, since that is how you found this page.

May 03, 2013
this sucks
by: Anonymous

I'm a UMA student now and this is a homework assignment. The instructors tell use to use the internet to help use not to cheat. I thought I found a good thing with this comment until I got to the end of it and realized that someone was cheating. How can you be a successful insurance biller if you cheat on the assignments? This page was full of great information, but I have to get my information from elsewhere now. Because someone didn't want to do the work for themselves. They SUCK!!

Apr 18, 2013
SUCKS!!!!!!!!!!!!
by: SweetKitty

I'ma UMA student and I'm lost for words right now. Can't find anything even reading in my IHMO book ow well guess I have to ask my mom.

Apr 12, 2013
don't wanna tell
by: Anonymous

You can ask to do your externship somewhere else.! Tell school not working.u can say conflicts. Ask to b changed. I did my externship in several places.say u want experience in er Dr occasion clinic ect. I did 4 different places for the experience.

Apr 12, 2013
Be Responsible
by: Anonymous

I worked with a doctor doing this. Billed procedures not performed and also billed bloodwork for patients without ins to other patients with ins. Everyone in office is afraid of losing their job so afraid to tell. The office mngr tells them its ok and they're afraid of her and getting fired. I worked there 7 years and when I said something I was fired. I was accused of something I didn't do but no way to prove it. So whatcha gonna do? Find another job pronto!

Feb 16, 2013
MA Extern Seeing Things
by: Ess

I'm in a pickle right now. I see things being performed right before my eyes that I know are wrong. I stopped going in (I'm an extern) because I am physically sick over it. My conscience is physically reacting (headaches, insomnia, exhaustion).

I jeopardize finishing my externship in a timely manner by leaving since I'm only halfway finished. I need to start working but this prolongs it.

I decided patient safety comes before my jobhunting and externship. This is a perfect real life ethical situation for an MA.

Do the right thing. Regardless of how inconvenient it is or how many people think you are a crazy "do gooder" and should only think about finishing your externship quickly.

Safety measures, HIPAA, infection control....all those things ALWAYS come first.

Feb 01, 2013
this sucks
by: Anonymous

I am also at UMA and am wondering about the same question and have not found anything

Dec 09, 2012
Jerks!
by: Anonymous

you people are snotty jerks, obviously you were doing the same thing, asking the question at hand, because you ended up on this page, that's calling the kettle black. Not any one of you people calling others scammers and cheaters are better than anyone else. You did the same thing. Get a life seriously.

Dec 09, 2012
UMA Question Duh
by: Anonymous

Its funny that like 10 people on here are going to UMA right now and wondering what to do, however getting an opinion isn't cheating, to whoever wrote that snotty comment down there!!! Just saying..

Dec 06, 2012
haha
by: Anonymous

I am in UMA too. Doing the assignment now.

Nov 13, 2012
wow
by: Anonymous

So I am a student at UMA and I was looking up the legal procedure in making a report to the insurance carrier and came across this post. I laughed my butt off.

Oct 30, 2012
A real discussion
by: Anonymous

I too have this question in my UMA class as a discussion question. I wish UMA would put their discussions in this format so students may have a class discussion of the topic.

Sep 18, 2012
UMA essay fraud
by: Anonymous

Wow, people are really posting this question up as if it actually happened to them? Isn't it obvious that this answer can't be found on the internet? This question is more of an ethical question. If anything, instead of posting your essay question, you could have actually done a little research on proper procedures for reporting fraud and then draw your own conclusions from there.

I hope that A feels great with the knowledge that you cheated to get it.

Sep 07, 2012
LESSONS LEARNED
by: Anonymous

Whether this has happened or not, I'm a student at UMA and the professors tell you to use the web for your essays! You just need to create links so you're not just copying what you read. However you the student as I should know the answer to this without the internet. You need to protect yourself, have proof, report the doctor if fraud occurs etc.. noone needs to judge a student that is trying to do good and get a grade!

Jul 25, 2012
This is a question in my UMA Course
by:

I was doing research on the internet about an essay question and came across this web site amazingly someone is going thru the same thing word for word that our essay question asks whoever it is looks on google every week for their essay question answers cant wait till they have to take the final to become a biller and coder lol you are only cheating yourself!

May 22, 2012
Person who posted this question is a scammer
by: Anonymous

What a scam... this is a question used for a medical billing class... what a cheap way to get an answer. Lying and cheating. That is no way to get through school, or to be a medical biller and coder. You are supposed to have integrity and honesty.. this just shows you do not have either. The submitter that is.
How terrible.
I at least do research, don't pose as someone who I am not.

Thanks for the comment and for identifying this for what it is. This is the second comment we've received on this. We didn't realize this was a response to someone's homework assignment or we would not have answered.

Apr 18, 2012
NOT REAL
by: Anonymous

Yeah Right. That situation never happened. You just needed the answer to your essay question when you were a medical billing/coding student at UMA.

Apr 28, 2011
Thank you
by: Anonymous

Thank you as I have just what you relayed in your letter and I also put in my two week notice.

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