If You See Fraud in Your Workplace, Should You Blow the Whistle?

Julie Shenkman
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Health care fraud occurs in all facets of the industry, including home health, hospitals, physician offices, nursing homes and other facilities. Most fraud cases revolve around Medicare and insurance fraud. If you see fraud in the workplace, report illegal actions immediately to the appropriate authorities. It is your duty to protect the health of patients while maintaining your own protection.

Health care fraud costs the United States approximately $80 billion per year. If caught, people who participate in fraud face jail time, fines and permanent loss of licensure. Due to the lucrative nature of the health care industry, whistleblower protection needs to become a priority in cases of fraud.

People benefit from these illegal actions through stolen health care information, patient kickbacks and claims for fictitious care. Perpetrators also file duplicate claims for the same service, alter medications to make it seem like someone needs more medicine, alter descriptions of medical services to something more expensive or even prescribe unnecessary treatments. Potential criminals then pocket the extra money paid by insurance companies for services that only existed on paper. Health care fraud has become so rampant that up to 10 percent of every taxpayer dollar spent on health care goes towards paying fraudulent claims. Fraud reporting helps reduce wasteful spending in an overburdened system.

Although patient care remains a priority, you may run across the patient billing process and other financial aspects of providing medical care as an entry-level employee observing managers. Upper-level administrators typically have intimate knowledge of medical billing, health insurance law, financial regulations and accounting practices within the health care industry. You may observe fraud at any of these levels of management. Even if you are an innocent bystander, courts may implicate you if you witness health care fraud and then fail to act on it.

Whistleblower protection surrounding fraud takes many forms. Your first actions should be to report to your own supervisor. If you feel that your supervisor may have a role in health care fraud, consider talking to another supervisor on the same level as your boss. Follow the normal chain of command. If you find the upper echelon of your company may participate in fraud, inform an outside agency of the possibility.

Unfortunately, you may find yourself the target of harassment, reduced hours, firing or demotion for your potential whistleblowing activities. Keep detailed records of anything that happens to your status at work. Discuss your situation with an experienced health care attorney who may take your case. Most lawyers offer one free consultation before agreeing to take on your case.

The most important aspect of whistleblowing includes telling the truth, even though it takes courage to do so. Health care fraud is illegal, even if someone participates unknowingly. Courts may grant leniency to whistleblowers in exchange for information. If you see criminal activity, do the right thing and report what you have seen.


Photo courtesy of photostock at FreeDigitalPhotos.net

 

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  • Nancy Anderson
    Nancy Anderson

    @Iris thanks for your follow up. So very sorry that you have to deal with a situation like this but kudos to you for reporting it. Going broke certainly is no joke. Maybe you could take some of your skills and apply them to a position in a different field - outside of healthcare. Or maybe stay in healthcare but in a different capacity. Many times we get stuck in a rut and think that the job we are performing is the only job we can do. Not true. So try taking some of the free career assessments that are offered online and see if there isn't another career that you could start. We wish you all the best.

  • Iris C.
    Iris C.

    Nancy- Thank you. I've almost moved on. Although EEOC wouldn't have anything to do with my complaint, the State did and still is investigating-6 months later. The owner sold the company rather quickly and liquidated; so hopefully things have gotten better for the clients and staff. Following the chain of command (for this company) did not work and ended up on my annual evaluation that I 'complained about the program.' Six months later I received a 'letter of commendation' from the owner; two months later after taking a client safety complaint to the new Head of Admissions-I was terminated. Hmmm... If I could afford an attorney I would certainly retain one. Six months out-no unemployment-no job-no kidding. Going broke is no joke. The company is not going to care that you have a disabled spouse and/or child to care for. At least I can sleep at night knowing I made a small difference. Personally, and this is just my opinion-if your company is engaging in fraudulent behavior-and you want to keep your job. Report it. Now. Any state that you have signed as an 'at will' employee will terminate you for any reason, even if it's unfounded-the only protection is to report it first. Or if you have been discriminated against and have written proof and witnesses who will testify on your behalf. Unfortunately, if you don't sign the 'at will' document, they probably won't hire you.

  • Nancy Anderson
    Nancy Anderson

    @Patricia so sorry you went through something like that and shame on that supervisor! It boggles my mind that companies would respond in that manner. If there is an issues - especially one that could cost an employee their life - you would think that companies would welcome hearing about so that can correct it instead of having to deal with a wrongful death lawsuit! Certainly agree that "talking" about it among your coworkers is a bad idea. But thanks for the information to find an attorney and let them handle it.

  • Patricia N.
    Patricia N.

    What terrible advice - go to your supervisor ? did that ONCE- got marched out the door and my keys taken from me and unemployment does not pay that much - supervisor will protect the corporation- not you - go to a lawyer that specializes in whistleblowing - lawsuits are great fantasy- but take years to complete - you will go broke - see an attorney first and keep your mouth shut

  • Nancy Anderson
    Nancy Anderson

    @Iris it sounds like you might have gone through this. So sorry that you were treated with disrespect from the company. It would be worth hiring a lawyer - even if it's just to get a small settlement from the company such as maybe 6 months salary and an excellent recommendation. Hopefully you have moved on from this and found a great job.

  • Iris C.
    Iris C.

    There may be a whistleblower protection law, but from experience, I hope you have another job lined up. My state is a 'at will" state. It's highly likely you will get fired anyway because they can pick or literally make up any excuse to fire you..whether the reason is valid or not. You will probably be awarded your unemployment benefits after a hearing when the hearing officer finds that you 'were not fired for cause or misconduct." Good luck getting an attorney to sue them. At will states leave the employees without protection. Just speaking with the company owners or administrators does not count that you have reported an issue.

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