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

by Anonymous

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)

Workers compensation fraud (or filing false claims) is not only unethical, it is considered a crime.

If you suspect a provider is committing insurance fraud, even if they are your employer, you should report it. If you are a participant and knowingly file claims that you know or suspect are fraudulent, you can be implicated. You are especially at risk if there is evidence that you knew the workers comp claims being submitted were fraudulent. In many situations filling false claims can be punishable with jail time.

Keep good documentation and records with names, dates, and any other specifics. Remember this is also for your own protection.

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

Hopefully all the procedures your provider is telling you to bill for are documented – on something like a superbill or his patient encounter notes – evidence that shows the provider 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.

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 flagrant and obvious fraud when the temptation may be to look the other way.

I understand 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.

I’m not an authority on workers comp but I believe the states have different laws regarding fraud and abuse. Do a Google search for your states insurance fraud agency to find specific information on how to report suspect fraud and what your responsibilities and rights or protections are.

Most states have a way for suspected fraud to be reported confidentially and most offer protection and sometimes rewards for those who report suspected fraud. Many may also have a way to report anonymously.

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.