Is Healthcare Fraud Happening At Your Workplace? Here Are 3 Silent Clues To Watch Out For…
In March 2015, a fourteen year-old girl with cerebral palsy died due to medicare fraud. Over the course of two years, she was severely neglected by her doctor, her nurse, and even her mother. At the time of death, she weighed 28 pounds and had been suffering multiple preventable infections including lice, open sores, and an impacted colon. Her name was Makayla Norman.
Makayla’s nurse submitted false claims about Makayla’s care. She reported almost daily visits when, in reality, she really only stopped by the patient’s house a few times per month, sometimes not even going inside the house but simply picking up the mother for shopping trips.
In tragic cases such as this, fraud becomes more than just a white collar crime of greed and misleading paper trails, indeed it is all too often the beginning of serious illness and death.
It’s sad to say, but in today’s healthcare system, patients are not only in danger from the medical conditions they seek treatment for, but also from the very people and facilities they have interested their care to.
We’ve all heard the phrase “if you see something, say something,” and as a nurse you’re wired with the responsibility to look out for your patients.
Nurses are always on the front lines of patient advocacy, and often ranked as the number 1 trusted health care professionals. As a nurse you spend your time communicating with and observing patients, and therefore observing everything from new symptoms to the sometimes questionable behavior of physicians.
But what are some of the warning signs that fraud is happening right underneath your nose? How do you know what to look out for? And how do you confidentially (and courageously) report fraud if you discover it is happening?
Here are a few helpful questions worth asking if you suspect fraud in your workplace:
1. Are you being asked to misrepresent services for billing purposes?
“Misrepresenting” services can take on a number of forms such as:
- Claiming procedures were performed, but they never actually happened (for example, showing a movie to patients but reporting it as “group therapy”)
- “Upcoding” or falsely labeling treatments so they cost more money.
- Claiming patients were treated more often than they actually were. (For example, this is what happened with Makayla Norman.)
- Billing “steps” of a treatment separately – with the intent to raise the price – though it was one procedure.
Filing claims for misrepresented care is extremely dangerous because it allows doctors or other medical staff to cover up instances of horrible neglect, which could potentially lead to patient deaths if not caught in time.
Similarly, filing claims and charging for services that were never actually provided is equally as dangerous because patients can miss out on necessary treatments they require, or they may have serious symptoms that never get diagnosed, or they may simply fall through the cracks and be ignored altogether.
2. Do staff members regularly perform services that they are under-qualified for?
Have you ever witnessed instances where the supervising doctors submitted claims stating they performed the services rendered, when in fact it was performed by an under-qualified staff member?
This is also extremely dangerous because having under-qualified staff members perform medical services can lead to overlooked, life-threatening conditions.
For example, in Maryland, the CEO of a diagnostics company called Alpha Diagnostics was convicted of healthcare fraud that stole over $7.5 million from federally funded programs and resulted in at least two patient deaths1.
Their X-rays were misread by uncertified employees who failed to report congestive heart failure. Tragically one patient therefore never received acute care and died of the heart failure, and the other was wrongly cleared for surgery that resulted in death from significant bleeding during the operation.
3. Does your medical facility regularly waive deductibles and co-payments?
On the surface, this may sound like a “nice” thing to do, but often it’s a way to placate patients. If patients don’t have to pay to be seen or treated, they’re less likely to care if a string of inexplicable treatments are listed on their bills to Medicare.
False medical records (for example, listing treatments/surgeries that weren’t rendered or even necessary, medications that were never received, psychiatric or therapy visits that never happened) create a false medical history for patients. Not only is this medical identity theft, but it can also seriously complicate diagnoses down the road if an entire timeline of treatments, medications and sessions have been fabricated out of thin air.
False medical records can also decrease the amount of affordable care available to patients. If their policies have spending caps, money they were counting on previously can easily disappeared because of false claims they never knew about.
You Can Make a Difference And Save Lives
If you have the courage to step up and report fraud or other unethical practices at your workplace, please know that you ARE making a difference in this world, and you very well could be saving many lives.
However, there is a right way and a wrong way to report fraud. There is also a safe and confidential way.
There is an organization you can go to for guidance and help called the Whistleblower Justice Network. They help and partner with courageous individuals who want to step forward and do the right thing to STOP healthcare fraud. Utilizing whistleblower laws, they can aid you in safely and effectively bringing those who seek to defraud our already overwhelmed healthcare system and harm patients to justice.
If you have any information regarding healthcare fraud, including schemes involving kickbacks, unnecessary medical procedures, kickbacks to providers or other fraudulent activities, Whistleblower Justice Network can help you step forward. Working alongside world-class legal counsel, they help build your successful case, and ensure that all possible whistleblower options (including compensation) are fully explored on your behalf.
Find out how the Whistleblower Justice Network can help you. Visit them at www.whistleblowerjustice.net, or call 844-WJN-4ALL. You’ll be glad you did.