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How to Report Medicare Fraud and False Claims Act

Updated on February 10, 2013

On July 16 , 2011, 94 people were arrested and accused of healthcare fraud, submitting claims to the government that amounted to more than $251 million dollars in procedures and services that were never performed. Medicare beneficiaries were involved, allowing the healthcare providers to bill for the services under their ID number, accepting cash payments in return.

In 2009, the Department of Justice collected approximately $1.63 billion dollars in settlements and judgments against providers accused of fraud. This number is small in relation to the estimated $60 billion per year that is lost to Medicare fraud, and this is only an estimate. There are no accurate numbers, because not everyone who commits fraud is caught. The federal government, usually, must rely on an employee to step forward and report his or her employer.

This takes an incredible amount of courage. It also requires that an employee has a conscience. Unfortunately, it is easy for employees to ignore what is occurring. Some people have a “who cares?” attitude. Other people are afraid of losing their job. However, an employee's failure to report fraud makes them just as guilty as the provider and can include fines and be found guilty of a misdemeanor.

If you believe your employer is committing fraud and abuse, it is my hope that after reading this, you will make the right decision and report your employer. Not only is your employer ripping off taxpayers, but unsuspecting, sick senior patients, too. If your employer is committing Medicare fraud, a federal offense, then certainly your employer is committing fraud and abuse against private insurance companies and cash-pay patients--you probably are well aware of this.

I’m going to outline how to identify Medicare fraud, how to report it, what information you need to supply to the government, what to expect after you report it, and how to pursue a False Claims Act.

IDENTIFYING MEDICARE FRAUD

Listed below are the most common types of Medicare fraud encountered in a provider's office.

Billing for Services Not Performed or Items Not Furnished:

Self-explanatory and easy to prove, this is commonly done with diagnostic testing (labs, x-rays). This type of fraud is easy to prove because medical records do not exist. However, sometimes falsifying medical records comes into play when a provider bills for a procedure that is routinely performed in the office or an item is supplied by the office. When the patient receives a remittance advice (RA) from Medicare, their first phone call is usually to the provider--not to Medicare. The patients are informed there was an error and to disregard the RA. When patient co-insurance amounts are consistently written off for these procedures or items, this is a good indication the procedures were never performed and/or items were never supplied.

Up-coding:

This happens when the bill reflects a higher procedure than what was performed in order to obtain higher reimbursement. Only 2% of Medicare claims are audited to look for this type of fraud, so it is highly unlikely that your employer will ever be caught for this practice unless you report it.

Misrepresentation:

Medicare will only pay for procedures that justify medical necessity in relation to the diagnosis code. Providers will often change a diagnosis code in order to obtain procedure reimbursement for costly diagnostic testing, like nerve conduction studies and surgeries. Additionally, procedure codes are often changed to depict a different service than what was actually performed when Medicare does not cover a certain procedure.

Unbundling:

Unbundling is common with surgical procedures, laboratory tests, and x-rays. Unbundling breaks down components that are included in one service and billing for each item separately. For example, a common lab test is a CBC which includes a dozen or so separate tests. Instead of billing for a CBC, the unbundled bill would reflect all tests performed by listing them separately. Sometimes, in order to avoid the chance that Medicare does an automatic bundling, the tests will be divvied up by utilizing more than one bill.

REPORTING YOUR EMPLOYER

There are two ways to report fraud. The first, and least preferable, is by an anonymous tip. By submitting an anonymous tip, your information is going to be on the low end of priorities. It may never be reviewed for a number of reasons, from lack of credibility to incomplete information.

If, however, you do decide to take this route, I would recommend that you spend both the time and money required to submit a detailed explanation. Include examples of the fraud being committed, including copies of documents. The more information you submit, the more likely it will be investigated. Information on what type of documents to include is below.

You can report fraud, anonymously, to one of two entities:

Office of Inspector General

Department of Health and Human Services

Attention: Hotline

PO Box 23489

Washington, DC 20026

You can also call OIG and speak with someone and still remain anonymous. 800-447-8477.

FBI: You can call or mail in a complaint to your local FBI office. The link to obtain the mailing address and phone number to your local FBI office can be found here.

If you have decided to report your employer and don’t feel the need to remain anonymous, contact your local FBI office and ask to speak with an agent that works in the Medicare Fraud and Abuse Department and schedule an appointment to meet.

ESSENTIAL INFORMATION SUPPORTING YOUR COMPLAINT

Both the OIG and the FBI’s Fraud and Abuse Department will require proof of the allegations you are making. You will need supporting documentation: the provider's name and all relevant information; patient information, including names, dates of birth and id numbers; dates of service; dates of payments; copies of medical records, super bills, RAs, and account printouts; any e-mails that could help prove the accusation.  Never take original documents, unless they are internal documents (company related information:  employee handouts, employee handbook, company policies, etc.).

(If you are submitting an anonymous tip and mailing the information, attach a piece of paper to each document describing what each document represents. Explain the fraud in as much detail as possible.)

If you are meeting with an FBI agent, you can write this information down on paper, or make copies of all of the information. You will not be committing a crime by doing this. Despite confidentiality agreements you have likely signed with your employer, when an employer is committing fraud and it is your intention to report it, you will not be prosecuted by any entity for taking these documents. You are not doing anything wrong, and as a matter of fact, you are doing the right thing by gathering as much information as possible. The more information the government has, the easier and faster it will be to conclude an investigation.

Removing the information from your employer’s office might be problematic but can be done in small increments or, even, large increments. Bringing a book to work with you and folding up documents and placing them inside is one way to do this; utilizing a purse is another approach.

To remove documents in large quantities, bringing a small cooler for “lunch” is very handy. By keeping your lunch at your desk, you can shove numerous documents inside of it all day long, and nobody will ever know.

WHAT TO EXPECT WHEN YOU MEET WITH THE FBI

Once you report your employer to the appropriate authorities and set up an appointment to meet with the agent(s), you will be expected to outline, with great detail, what is occurring. Bring all relevant documents with you to this meeting, and the more documents you have, the better. The agents will usually be able to determine at the conclusion of the meeting if the information you have is worthy of an investigation.

You will be asked to what extent you are willing to cooperate. This decision is completely up to you. You may only want to give the information you have supplied at the time of the meeting and no more. If you brought only a small number of documents or no documents with you, there will not be a high-priority investigation. If you brought in hundreds of documents to support your claim, they are more likely to pursue it without your direct involvement.

If you agree to cooperate and obtain more information in order to speed up an investigation, the FBI will ask you for specific documents like medical records, specific account numbers and printouts, e-mails, etc.

You will be expected to sign a form that shows you are willing to be a witness and cooperate. You will be given a code name, because you will remain anonymous to everyone except the agents that you are dealing with directly.

The FBI might ask you to wear a wire to engage people in conversation. This is a great opportunity to speed up an investigation and can feel exhilarating when a discussion occurs about the fraud, and you are able to get it on record.

PURSUING A FALSE CLAIMS ACT

The False Claims Act is federal legislation that encourages people, called whistleblowers, to come forward and report fraud by giving the whistleblower a financial incentive. The financial incentive is anywhere from 15%-30% of what the government recovers from the provider. The legislation also provides for attorney fees and expenses separately, so the amount granted to a whistleblower is the amount a whistleblower keeps.

A whistleblower must find an attorney to qualify for the award that specializes in qui tam. The attorney files a lawsuit, called qui tam, and it is sealed in order to protect a whistleblower's anonymity and preserve the integrity of an investigation. It is sealed when filed, and it remains sealed for the duration of an investigation. Nobody, including press, defendants, and members of the public and court, has access to the contents inside. Also, because the legislation provides for attorney fees, an attorney will not charge any fees associated with filing a qui tam lawsuit.

It is important to realize that only one person is allowed to file a qui tam lawsuit. If someone has already filed a qui tam, you are not eligible to file; however, your cooperation would still be appreciated by the government, the taxpayers, the patients, and future employees of the provider.

Deciding to pursue a qui tam lawsuit can be a difficult decision. However, if your cooperation has been detrimental to an investigation, this means you have, undoubtedly, supplied the authorities with an incredible amount of valuable information, which can sometimes be extremely stressful.

 

Medicare fraud is a dirty, white-collar crime committed by cowards. These cowards hide their criminal activity behind a respected profession with no regard for anybody except themselves. They also expect employees to take part in the criminal activity. Most of the time, there is only one person that is capable of putting an end to the fraud and abuse, and that person is you, the employee.

Though reporting your employer for committing Medicare fraud might not be an easy thing to do for some people, it is the right thing to do. It is something to be extremely proud of; it is honorable, courageous, and admirable--all of which are wonderful qualities for a person to possess.

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    • profile image

      Anonymous 3 months ago

      If home health patient is not home bound, seen driving 3 times in past 2 weeks, by home health staff, administrator notified and refuses to allow discharge, as per Medicare guidelines, is this Medicare fraud?

    • Deni Edwards profile image
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      Deni Edwards 4 years ago from california

      The above article really gives step-by-step instructions on how to go about reporting your employer. Even without any paperwork, you could report your employer.

    • profile image

      Upset and aggravated. 4 years ago

      I worked for a Dr. who I have found out to of been billing for items not received by patients and upcoding all office visits and procedures. I recelntly found this out because the office manager who does the billing had stated that she was getting very uncomfortable with how things were being submitted to medicare and that we were going to get in BIG trouble and the Dr was going to jail. For instance I did not know that you can not bill for an item unless it has been received by the patient. Well the office has been billing the patients insurance for items such as braces then sending the items out to be made once payment is received. I was appalled to find out that the treatment the patient was receiving from our office was falsely billed as an office visit when the patient did not even see the Dr. only the medical assistant. I also found out that specific codes were billed for braces and those codes were for items not put on the braces. I have no idea how to report this Dr. I worked for him for 8 years!!! I left there because I was fired for bringing this information to his attention and because I was not going to work for a company any longer that subjected me to the constant lying and decieving on a daily basis. I was pulled into a room in front of every one at the office and told that I was to answer questions and when I said I was not going to answer any questions and that I was going to just go ahead and go. (I meant leave for the rest of the after noon) it was said that I quit and I was asked to leave my keys and that there was nothing that could be done for me to work there any longer. I was humiliated and lied too. I was also told that I will go to jail before the Dr. does simply because I am too stupid to get out of it. I was also told that I would be blamed for things that were wrongly billed and items not recevied along with upcoding and upbilling because he would tell the whomever investigated that he had no idea what we were billing and doing in his office. I do not have any paperwork from the office because I was not prepared to be let go so quickly, so if anyone can please give me any information on how to report him and have his office practices investigated it would be helpful.

    • Deni Edwards profile image
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      Deni Edwards 4 years ago from california

      This simply isn't enough information.

    • profile image

      izzy 5 years ago

      I work at a hospital where many of the cardiologist are doing a large amount of cardiac catherizations, that are not necessary. Isn't there away to alert medicare and medicad by area or zip cope of unecessary testing.

    • Deni Edwards profile image
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      Deni Edwards 5 years ago from california

      It isn't illegal unless he is adding stuff that wasn't done, for example, adding a blood pressure or weight. A lot of physicians review charts at the end of the day or even on the weekends, so this isn't something that is illegal.

      If the physicians are adding quite a bit of documentation, what would be best is to add an addendum to the chart notes.

    • profile image

      BeeBee 5 years ago

      I am working at a clinic and notice a doctor creates notes in his chart the same day he sees the patients. He submits all bills the same day based on the created process in the practice. Nevertheless, he comes back to the notes during the weekend or later to complete the comprehensive notes in detail to ensure that it is supporting his proper coding, especially the EMR is always holding people back from good patient care. He is over cautious I think, but I wonder if that's is legal if you signed the notes after the billed date?

    • profile image

      SeeBee 5 years ago

      Thanks for your response! Approximately 55% of the patients are on Medicare/Medicaid/Tricare... that equivocates to a lot of tax payer money!

    • Deni Edwards profile image
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      Deni Edwards 5 years ago from california

      When you report suspected fraud to the authorities, there is no HIPAA violation. HIPAA doesn't apply to giving authorities information about possible fraud a provider might be committing. So there isn't reason to be fearful of this.

      Keep in mind that what the authorities will investigate are the cases that include federal funding (Medicare, Tricare, Medicaid patients). As for the other types of insurances--commercial plans--you could always put a phone call into the insurance companies' fraud and abuse department.

    • profile image

      SeeBee 5 years ago

      If I work for a physician, and if I know they up code E/M visits, and also have a non-certified M.A. doing things that are only reimbursable IF the physician performs the service, and I don't report it, I could be fined and possibly serve prison time?

      What about every time a patient comes to the office, an electronic record is completed, saying that a breast exam was done (almost laughable... really, every 3 months to get their anti-hypertensives!) , or that the abdomen was palpated, on and on... NEVER DONE because the doc never left their chair!! Or, how about procedures that are clearly defined "must be performed by physician" being billed, when an employee actually performed the procedure?

      If one is afraid to report because of HIPAA violoation, what do you suggest?? Not to mention the verbal abuse one has endured from the physician's spouse over the years, i.e. being called STUPID and a non-mentionable word... I know, another topic! Or, not paying overtime to employees, but instead giving "comp time"...

      This all makes me wanna spilllllllllllllll the beans... but, one might be afraid to. Advice???

    • Deni Edwards profile image
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      Deni Edwards 5 years ago from california

      I would recommend not doing it anonymously. Understand that when you give this information to the government, your name is not released to the providers unless you decide to file a lawsuit--and even then, it is sealed--meaning nobody has access to it. You can ask to meet with the FBI, give them a run down of what is going on, and then they can ask you questions so you are able to give them exactly what they need to pursue a case. You could meet with them just once or twice, and be done with it. Your name would not be given to your boss.

      If you want to give an anonymous tip, again, be very detailed. Don't just say, "they have billed for a service using someone else's NPI" or vaguely stating that non-approved providers are providing services.

      State exactly what the services are, who is rendering the service, and which provider they are billing under.

      You don't want to file a complaint with the Medicaid office.

      You want to go to the FBI or to the anonymous tip website/phone number of the government that I provided in the article. So, make sure you go to the correct people to report this.

    • profile image

      Tabwee 5 years ago

      Ok, so I read your response to my question. I do not have access to remittance information to show that they billed for the services, but I have access to one of the alleged offenses of having unapproved providers working, meaning they have billed for a service using someone else's NPI. I have info showing the providers were declined and proof that they completed and were paid for services for the company. Will this be enough information for an investigation?

    • Deni Edwards profile image
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      Deni Edwards 5 years ago from california

      Hi, Drew--

      I'm not very familiar with out-of-state Medicaid. I know that the hospital I work for has two people that deal with out-of-state Medicaid patients, and we do collect payment.

      I also know that this is often difficult for providers, and there are actually businesses that specialize in collecting out-of-state Medicaid for providers.

      I believe what happens is that the state that the patient is enrolled with must be contacted, and some forms must be filled out by the provider. If you work for a large provider, like a hospital, I don't know why the provider wouldn't want to pursue payment.

      As far as writing off the balances for out-of-state Medicaid patients, I can only assume, which isn't a good thing to do, and my assumption would be that you shouldn't write them off, but definitely NOT bill the patient.

    • monicamelendez profile image

      monicamelendez 5 years ago from Salt Lake City

      And taxpayers have to foot the bill. I'm glad they're catching people.

    • profile image

      big daddy 5 years ago

      Rock it out Deni! Your advise is spot on. I've got a suit going on now. These companies are so stupid, but Medicare can't audit them all...I hope competetive b

      id takes them down.

    • profile image

      DReW 5 years ago

      Sorry for the typos...I'm on a tablet. It just seems odd that my company adjusts off balances for patients with an oon medicaid. We have finacial assistance that they will qualify for, but is it ok to assume and adjust?

    • profile image

      DReW 5 years ago

      Hi Deni. I want to get something straight. Must status Medicaid programs that my company is OON will not verify patient benefits. Is it ok to just adjust them off necause the patie nt claims they have Medicaid? My company just adjusts off balances owed from patients who claim they have Medicaid from a non contracted state because we aren't able to verify they have coverage.

    • Deni Edwards profile image
      Author

      Deni Edwards 5 years ago from california

      I don't quite understand what you are saying here. It sounds as if you are generalizing cases of fraud, in which case you are correct that there are laws in place. But why in the world have you been writing to the government since 1999 about this? The government does investigate cases like what you have mentioned. You're not telling them anything that they don't already know.

      If you are working for an employer who is in violation of these laws, you simply report it with your first-hand knowledge and examples. But, it sounds like you are not doing this--it sounds as if you are just rambling about the types of fraud that occurs.

    • profile image

      johnnybgoode 5 years ago

      Around the country medicare allowed the forming of Hospital Owned /Affiliated Home Medical Equipment (HME) Companies over a decade ago. I have written OIG, Medicare Fraud Division, etc etc since 1999 explaining why I feel their daily practices in 3 areas are illegal due to their structure but the Gov't will not acknowledge if I am right or if I am wrong & the fraud continues. I've been in HME business for 20 years as a Manager and what these Hosp owned HME's do on a daily basis would result in any other independent HME dealer to be thrown in jail or fined. Briefly, here are 3 areas of violation:

      #1 Doc who works for hospital/paid by them writes RX for HME & refers order to their own HME business : Violates Stark law, physician referring patient to HME he has direct or indirect financial relationship with.

      #2 Person in Doc's office who is paid by Hospital/Health System fills out Certificate of Medical Necessity (CMN) for HME ordered & Doc signs it : Violation Bal. Budget ACT 1997 & False Claims Act: Anyone with any financial ties/interest to HME company cannot complete any part of CMN.

      #3 Hosptial's paid/compensated Respiratory Therapist O2 sat tests a patient to see if they qualify for O2, then O2 RX is written by Hospital Doc & O2 RX filled by Hosp Owned HME: Violation CMS rule: any HME that has any type of financial ties/relationship with the testing lab/facility (in this case the hospital) it's viewed as if the HME did the O2 sat test themselves which is illegal! Anyway, I feel this is the biggest case of Medicare Fraud going on everyday around the country but gov't refuses to acknowledge it.

    • Deni Edwards profile image
      Author

      Deni Edwards 5 years ago from california

      Yes, you could still be a whistleblower if you do not work there, it is much more difficult to get the information that is needed while you are not employed with the office, of course. Because, obviously, there will be questions that you may not be able to answer without some hands-on knowledge to investigate.

      You would also need more examples of billing for procedures not performed. I suspect that if they are doing this, there are other things that the office is doing?

      Keep in mind that these whistleblower lawsuits have to be regarding federal and/or state funds--people with Medicare, Tricare, Medicaid. And you would want to have examples of obtaining payment for these.

      As far as a doctor's visit along with a procedure, this is actually fine. The thing is, physicians do not like to do a procedure during the office visit, because often times insurance companies will not pay for it. It has to be billed correctly with a modifier indicating the procedure that was performed (if the office visit was for a separate diagnosis or problem) was separate from the visit. If not, then the office visit is not payable. This is why your docs said that they don't like to do a procedure the same day as an office visit.

      An example of this would be if someone came in for a blood pressure check and pointed out to the doc that there is a growth on his/her arm. If the doctor decides to biopsy the mole, the procedure is billed with the mole diagnosis and a modifier, and the office visit is billed with the hypertension diagnosis.

      If a patient comes in to just have a mole looked at, the procedure is performed, but the office visit is not payable--it is bundled with the procedure. This is why your docs will reschedule the patients--and I find this to be unethical, but it is not illegal.

    • profile image

      Notsureyet 5 years ago

      I just got fired from an office that is up coding and biling for procedures not done,example every pt has a urinalysis done but the drs only use microscope if its positive for something however all pts are billed for ua with microscopy.i no longer am there but its surely still going on as well as billing for office reg visit and a procedure visit for same time,a nono im told by the drs.could I still be a wstlblower even tho im no longer working there?

    • Deni Edwards profile image
      Author

      Deni Edwards 5 years ago from california

      Are you saying that your physician's office didn't have a scale and the equipment needed to take someone's blood pressure?

      These are two common things that are always done in a doctor's office.

      If the patient's vitals were not taken, and the office still input data into the patient's chart, this would be falsifying medical records, of course.

      However, the only significant part of this that might pertain to Medicare fraud--would be billing for a higher level office visit, maybe. But, since the data was falsified, I can't imagine that the physician would address high blood pressure (that was fake) into an office visit resulting with a diagnosis of hypertension. So, if the physician billed for an office visit and diagnosed someone with hypertension, for example, then yes.

      But, really, this isn't something that has anything to do with Medicare fraud.

      But falsifying medical records, yes.

    • profile image

      HP 5 years ago

      I left a job where I was being "told" to input data (height/weight/blood pressure) for which our office was not equiped to obtain that particular data. These are required for "meaningful use". I left because I considered this fraudulent and I did contact medicare. I have heard nothing from them (and it has been 4 months). Was I incorrect in thinking that is fraudulent?

    • Deni Edwards profile image
      Author

      Deni Edwards 5 years ago from california

      That is correct. If you report anonymously, and you do not give thorough and complete information, the government may choose to go after cases where they have cooperating witnesses first.

      Understand that it is costly to investigate and very time consuming, too. A simple point in the right direction isn't enough. If you don't want to come forward, I did outline in the article, very specifically, what you should do.

      If your complaint was short--like what you just wrote in the comment box--this is not enough information at all. They need examples. They need the provider's info, including the provider id#, UPIN, etc. They need examples of cases where the doctor has billed for services that were not rendered and examples of payments obtained for these services. They need actual evidence.

      Without a cooperating witness, you need to give them as much detailed and technical information as possible.

    • profile image

      Tabwee 5 years ago

      So, I currently work for a Rehabilitative Mental Health treatment center. I ran into your article because I recently placed an anonymous tip with Medicaid about my boss. Basically, she has been billing for services that have not been completed, letting people work who are not approved providers, and doesn't do therapeutic exercises with her clients. The reason I know all of. I had to report it because I couldn't take it anymore. I just hope that they don't find out that I told. So even though I reported the information, it may not get investigated?

    • Deni Edwards profile image
      Author

      Deni Edwards 5 years ago from california

      Hi, Drew--

      Hope everything is going well in your situation...

      When a patient has Medi-Medi, it is not uncommon that balances are written off--Medicaid's allowable is usually a lot less than Medicare--but the thing is, Medicaid MUST be billed before the balances are adjusted off--the balances can't just be written off.

      And if the patient has a secondary insurance, it should be billed whether or not it is out of network. Sometimes, even, the providers will provide a claim form for the patients to bill their 2ndary insurance. This is acceptable, too.

    • profile image

      DReW 5 years ago

      I contacted you a few months ago and keep checking your blog...you rock! The company I work for does the same thing that "loopy" is talking about. If a patient has Medicare and the secondary insurance is Medicaid from a non-contracted state, they just write off the balance and don't bill the patient (unless by mistake). However, if the patient has a secondary insurance that is out of network they bill the patient.

    • Deni Edwards profile image
      Author

      Deni Edwards 5 years ago from california

      Interstate Medicaid is not uncommon. It doesn't matter that the provider is not contracted, because at the point of seeing the patient (or after seeing the patient), the provider only needs to fill out the necessary information from the patient's home plan (the state the patient is signed on with Medicaid). Sometimes, however, this can be loads of paperwork, but it needs to be done.

      When you say that the company is adjusting the balances for patients with Medicaid, this indicates, to me, that Medicaid is being billed for the out-of-state patients. This also indicates that your provider is pursuing the proper channels to become contracted with that patient's Medicaid state/plan.

      As far as adjusting off the balances, no. Like many people on this comment section have pointed out, the providers that they work for are adjusting off balances, and this should not be done. A bill needs to be submitted to the patient, showing an attempt at collection, before any balance is adjusted off.

      The "waiver program" you are referring to...is this some sort of company program that when patients are approved, the patient balances are written off? If so, this is a no-no.

    • profile image

      loopy 5 years ago

      I work for a company that will adjust or write-off balances for patients that have Medicaid from a state that we are not contracted with. We have a waiver program that is so stupid 90% of people that apply are approved. Actually, the company doesn't even know exactly what % are approved. We actually post the financial guidelines on our statements. Is it OK to adjust the balances because we are OON with Medicaid. They don't do that for people with a private secondary insurance.

    • Deni Edwards profile image
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      Deni Edwards 5 years ago from california

      Bravo!

    • profile image

      jojo 5 years ago

      Unforsure: Take Deni's advice I did. I posted on here (under a different name because of my lawsuit.) I was in a similar situation. I knew something was wrong but didnt know what. I asked questions and the answers didn't make sense. Deni gave me advice. I found a lawyer. Think about the patient. What if that was your parent. My lawyer isn't local but has local contacts. It's not about the reward. Believe me, it's scary and a rollercoaster of emotions as your boss "fixes things". Bottom line, it's wrong. If I walk away with $5, at least theives are out of business.

    • Deni Edwards profile image
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      Deni Edwards 5 years ago from california

      There are no excuses that are accepted when fraud occurs.

      "I didn't know," doesn't work and, as a matter of fact, is quite common and, frankly, most of the time untrue. It doesn't ever hold water with the government in a case of fraud.

      Not billing for equipment because the reimbursement is low is intentional. This chair fiasco is ridiculous. The writing off of co-insurance is a massive no-no! Do not be naive.

      You have somehow become the person who is attempting to fix this mess, which is making you become more responsible for the mess, and especially if you don't report it. How will your career and family be impacted if you were to be implicated in a fraud scheme? You think it would be better that way?

      As far as fearing repercussions from the community, you seem to be under the impression that your community would be more accepting of ripping off taxpayers and seniors than they would be of truthfulness and honesty. Really?

      So my input is, obviously, do something about it. This is why I wrote an article about it. It's something I feel strongly about. It's a crime. It's a felony. It's wrong. It's stealing.

      I understand that it's a difficult thing to do--turning your employer in--but, this is why there are whistle blower laws--to reward those who do it and to help people do the right thing.

    • profile image

      unforsure 5 years ago

      My worry is that I really do not think that the owner know all of the guidlines and that she is not doing some of it intentanly..she relies on the office manager that can lie her way out of jail.(she does not know all the guidlines she just talks and it sounds like she knows excactly what she is talking about...but like I said they come to me for all the guideline answers,but I do not know them all)

      Also there is only 5 people that work in the office and I will have reprocushions with my community because with it being such a small company and a small town it will effect me negativly for the rest on my life.

      I want it to stop but I relly do not want it to be at the expense of my family and my career.

      what is your input on this?

    • Deni Edwards profile image
      Author

      Deni Edwards 5 years ago from california

      Yes, contact a Qui Tam attorney, one who specializes in "whistle blower" cases (essentially meaning you are blowing the whistle). Make sure you find one who specializes in qui tam lawsuits--you don't want an employment attorney.

      Do a search on the internet to find one in your area. If you live in a small city, you may want to find one that is in a larger city. Usually, you can contact the attorney via e-mail and through the attorney's website. The attorney will call you back.

      I have a link on this page about qui tam attorneys and the false claims act. You want one who has been successful, and certainly one that knows what they are doing.

      This doesn't cost any money; it is done on contingency.

      An attorney will help you sort out this mess, and probably ask you some questions you may not know the answers to--you will probably find out that your company is doing much more than what you know. Again, it's interesting that your company hires people who don't know what they are doing--it's done on purpose.

      Keep in mind, again, you want to immediately mention the lack of documentation, the patients not being billed, and this chair problem. It is attention-getting, because these sorts of things are so easily proven and come with a large recovery. The other things will eventually fall into place.

      Lastly, you are doing the absolute-right thing by moving forward with this. As you can see just from my comments on this one article, fraud is all over the place. A lot of providers are never even caught. I firmly believe that this is one of the reasons why healthcare costs are so sky-high.

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      unforsure 5 years ago

      I don't know if I'm understanding you correctly--the company is billing M/care for a chair and then billing the patient in addition (not the co-insurance, but the (ridiculously marked-up) cost)? If this is what is happening, no, this is outrageous

      You are correct they are billing Medicare for the lift mech..and then telling the patient they have to pay an extra 400 to 600 dollars for the chair it self.

      As far as setting up the equipment, I believe that this is usually part of the delivery service, but the people are usually trained techs, not simply delivery guys.

      I was told that it is the respritory therapist job to set up and do checks on the respratory equipment. I did not know if this was a true or not.

      Immediately mention the writing off of coinsurance, the lack of medical documentation, refusing to bill M/Care for smaller items, and that crazy scheme of billing M/care and the patient (how have they gotten away with that? or am I misunderstanding?) when you first contact an attorney.

      I am assuming they are writing it off, they are either doing that or nothing at all, it just sits there.

      They state that medicare will only pay for the lift mech but if you pull the lcd's there is a code for just the lift mech and also a code for the lift mech already mounted in the chair, they bill for just the lift mech and charge the patient 2 times the amount they pay for the whole mech and chair, so basically they are getting paid for the chair 3 times.

      I think that somethings they are doing they honestly do not know better but in my judgment this is there business so it should be there job to be educated and educate there employee's.

      I did not know simply should not be a valid pass for unexcuseable behavior that could be avoided if they would just do there job correctly.

      I think you are right about stating that they hire unknowlegable people because no one in that office know what they are doing including my office manager and the owner of the company, I have been there 3 years and they come to me with all there questions and I am trying to do the right thing but I do not have all the answers and I dont feel I should be held accountable when there is someone there that has been there for 11. I feel she should know more and should have been keeping up with guidlines.

      What do I need to do to go about contacting an attorney, Is there a certin type of attorney I should search for.

    • Deni Edwards profile image
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      Deni Edwards 5 years ago from california

      Obviously there are things going on in your company that should not be happening.

      Not billing patients for coinsurance. That's one.

      I don't know if I'm understanding you correctly--the company is billing M/care for a chair and then billing the patient in addition (not the co-insurance, but the (ridiculously marked-up) cost)? If this is what is happening, no, this is outrageous!

      This is what it sounds like to me: Your company likes to hire people that are not that knowledgeable for a reason. You're picking up on things, and making their lives a little unpleasant.

      My advice (and opinion) to you is this: stop suggesting things to your company, because if you keep it up, you will be fired, and the company will continue to do what it is doing. Find yourself an attorney.

      You can't FIX these things by bringing these "errors" to their attention. The company does not want these things fixed. Even you stated that much of their "fixing" is unwilling. They are doing it to appease you.

      You need to speak with an attorney who will ask you appropriate questions. You know that definitely there are some shady things going on here, and what you've indicated already is enough to make an attorney's ears perk up.

      As far as setting up the equipment, I believe that this is usually part of the delivery service, but the people are usually trained techs, not simply delivery guys.

      Everything else you have mentioned, though, is not okay.

      Immediately mention the writing off of coinsurance, the lack of medical documentation, refusing to bill M/Care for smaller items, and that crazy scheme of billing M/care and the patient (how have they gotten away with that? or am I misunderstanding?) when you first contact an attorney.

      Your company is so outrageous, you can't fix this problem. Understand that these "errors", many of them, are intentional, which makes it fraud.

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      unforsure 5 years ago

      I work for a DME compay for 3 years now, when I first started they showed me a little and then it was trial and error for me.

      with in this past year I have been reading the medicare LCDS I seen where the overnight oxemitry readings are supposed to be done and read by a IDTF facility, they had not been doing that and they knew that they where suppoed to (to my knowledge they are now doing that), per medicare the rx's on file for patients oxygen are not valid and they do not have medical documetation for half the equipment they are despensing out ( I have brought this to the owner attention and she is now trying to get medical documentation but the doctors never have documented what is required per the LCD guidlines).

      When we purch a piece of equipment is it legal to charge the patient 2 times the amount that we purch it for, for example a lift chair we order them and we pay no more than 300 dollars for the equipment and we bill medicare for the lift mechanism under the chair wich pays about 400 dollare then turn around and charge the patient 600 for the chair itself...there are several things that I beleive this company is doing wrong but I am not sure can I please get your input..also they do not bill for some things that medicare does cover telling the patient that medicare does not cover itlike bracewrist braces under 20 dollars and wound dressings(stating medicare does not pay enough to cover our cost.

      When a patient pays for a piece of equipment they do not always bill medicare so it can go toward the patinets deductable.

      Also as the girl above stated they do not bill for the co insurance stating that it is to much postage because the patient never pays, I have been billing patients currently for there co insurance owed.

      I do not want to be in trouble for things they are doing wrong and things I am unsure of and whenever I bring something to there attention they stat that the guidline is something new medicare has started and they did not know about it.

      Also is it illigal for the office manger and the delivery tech to be setting and despensing respiratory equipment...any information would be greatly apriciated

      I think they have just been putting out equipment and billing with out any knowledge of guidelines (well current guidlines ) now that I am learning of these things I am bringing it to there attention, some things they are unwillingly trying to correct. Somethings I dont think they care as long as they can get by with out medicare doing a audit.

    • Deni Edwards profile image
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      Deni Edwards 5 years ago from california

      You may want to contact an attorney for this case. Start sending e-mails to qui tam attorneys in your area.

      Medicare, as well as Medicaid, has an approved list of DME equipment. If your company is providing equipment/brands that are considered "off-the-shelf" (including some generics), there's a problem.

      It is also true that both Medicare and Medicaid will only pay for equipment from certain providers (providers that accept assignment).

      If the patients are receiving generic brands, and they don't know this, this is problem number one.

      If the supplier is not contracted, this is problem number two.

      The diabetic meters are concerning, but honestly, I'm not sure about the lancets.

      Call and/or e-mail an attorney.

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      MBBGPL 5 years ago

      My company bills the same amount regardless of brand. In fact, they want us to convert patients to our "preferred" diabetes meters and supplies that are advertised. Medicaid in some states is sending letters to patients telling them they will only pay for supplies from a specific provider, but my supervisor told me that this doesn't matter because we don't specify brand when billing. All diabetes meters and supplies are billed at the same price, maximum allowable amounts, regardless of brand. We also send generic lancets and control solution, unless the patient requests otherwise. Is this that blatant abuse or am I imagining it?

    • Deni Edwards profile image
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      Deni Edwards 5 years ago from california

      Yes, this is illegal! This is one of the most common types of DME fraud. It is easily proven, too. Documentation must exist that shows what the patient received, and this, among other things, includes serial numbers of the products that are sent to the patient and invoices.

      If this is happening at your place of employment, put a stop to it and turn them in.

    • profile image

      MBBGPL 5 years ago

      Is it legal to bill Medicare maximum allowable amounts for name brand DME equipment and send generic products to the patient?

    • Deni Edwards profile image
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      Deni Edwards 5 years ago from california

      Joe, congratulations for doing the right thing! I'm ecstatic!

      There was nothing at all good about what was occurring in your doc's office, and he deserves whatever he gets--for scamming patients and insurance companies and treating employees rotten all because he is money hungry.

      Good job, Joe!

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      Joe Shmow 5 years ago

      Hi all, Just wanted to throw in an update; about three months ago I posted about a local doctor who was having me x-ray patients(I am not certified)and billing as though he took the x-rays himself. I notified the D.P.E. and State Attornry General's office. Both have asked me to participate in a joint investigation. Both entities has also asked me to give sworn testimony, which I have done. In addation as of late Friday I have contacted and met with an attorney and spilled the beans. According to the attorney, with the information that I have devulged and to the entities that I have, this man is in quite a bit of hot water! I have done this not only to protect my future as a health-care provider, but also to protect the patients who have and continue to be seen via this money hungry man. He has placed profit above patient care. From what I understand(unkown time frame), the State Attorney General's Office is going to raid his office and shut him down! The will confiscate everything this man has in order to satisfy the amount of debt for which he has fraudulently billed for.

    • Deni Edwards profile image
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      Deni Edwards 5 years ago from california

      I told you it was slam-dunk here with the kickbacks and how your providers accounting is kept. Quite shocked, honestly, that they are so open about it.

      Yes, it is normal. Attorneys are busy, and you may actually receive a response back from an attorney (rather than a clerk). Just make sure you find an attorney who specializes in Qui Tam (whistleblower). Make sure he/she/firm has had successful prosecutions with Medicare fraud. You want a bio of the firm/attorney.

      Keep in mind only one person can file qui tam, so I recommend not sharing with your coworkers.

      Lastly, don't forget that the primary reason for doing this is to stop what is occurring. Don't let your company get away with these criminal acts--It sounds like you've just discovered the tip of the iceberg. If all else fails, and you exhaust all avenues with an attorney, schedule an appointment with the FBI fraud and abuse department. Be a cooperating witness, and you could always look for an attorney during the investigation.

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      DReW 5 years ago

      I took your advice. I've done a lot more research and realize what a joke this company is. No wonder I will never have Medicare. I did contact two law firms but they aren't being quick getting back to me. From what I've read about the anti-kickback laws the write-offs and adjustments this company make would be easily uncovered by the books. I've been talking to a lot of people I work with (not about this) and this company was shady from the start. Is it normal to wait several days for an attorney to call?

    • Deni Edwards profile image
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      Deni Edwards 5 years ago from california

      You are more than welcome. Just please understand that this isn't about giving patients their equipment when they have an outstanding balance on their accounts, it's about writing off these balances...it is one of the easiest things to prosecute a provider for, which is why I didn't touch on anti-kickback laws.

      Look up anti-kickback laws and find yourself an attorney.

      Surf the internet for settlements for these cases, they are huge.

      Turn them in, and if you find an attorney, you may find yourself well rewarded for being a good citizen.

      Best of luck to you.

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      DReW 5 years ago

      Thanks for your response. A lot of the balances are adjusted or written off due to untimely billing. There are patients that are just now being billed for dates of service in 2010. Even so, now that we are asking for a payment, if the patient says no, we still ship out their next order. I'll look up more information on the kick-back laws.

    • Deni Edwards profile image
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      Deni Edwards 5 years ago from california

      The problem is not what is going on at the present time:

      It is unlawful not to make reasonable collection attempts for patients responsible for M/Care coinsurance. There are only two reasons why collection can't occur--1) indigent and 2) reasonable attempts fail.

      Both of these reasons must be well documented/substantiated.

      So, the problem actually began when the coinsurance was not collected and would likely fall under kickback laws--waiving of collection of copays in order to increase business.

      This is huge. And I would ask what these patient balances were chalked up to in the accounting system. Have the balances remained open in the books? Have the balances been written off, and if so, to what category? Even small balance write-offs, in this case, is extremely unacceptable.

      Even if the balances were left open, if there is no documentation of attempts at collection for the 20%, this, in and of itself, is most likely enough to prove a kickback.

      Interestingly enough, M/Care may find out about this issue on it's own, since the provider is just beginning to collect from the patients. I wouldn't be surprised if patients call M/Care complaining about an old bill they are receiving.

      It is no wonder that your provider's office is not aggressively collecting the old coinsurance amounts...this is big-time trouble. The last thing your provider wants right now is for hundreds of patients going to Medicare to complain.

      Who to contact? If you understand what I'm saying about kickbacks, you should call the fraud hotline.

      If it were me, I would go straight to M/care about what has happened, but I would have done it three years ago when there were no collection attempts. Still, it's not too late.

      Keep in mind that this is also going to present a problem with deductibles being met/not being met, different calendar years, etc., because of all of these old bills. The patients may suffer financial hardships if they have been customers for years.

      This whole thing is a mess.

      I would report the provider if I were you. Again, go directly to M/Care, call the hotline (have the M/Care provider ID) or go straight to the FBI fraud and abuse department.

      To be perfectly honest, you are probably talking about a huge recovery on this, so you might want to think about finding an attorney for Qui Tam. The only thing, I don't think that you quite understand the kickback part of this, which is what this whole thing is about.

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      DReW 5 years ago

      I work for a DME company that sells diabetes supplies. When I started a year ago they told us not to tell patients if they had a balance on their account because Medicare only covers 80% of the supplies. We just kept placing orders and patients with Medicare as their only insurance were not being billed. If a patient had a secondary insurance they were sometimes billed but most patients with only Medicare were not. Even if they were billed, they were only sent three statements and there was no attempt to collect the payment. Patients with balances of several hundred dollars were allowed to continue ordering whether they paid or not. Now with the competitive bidding coming up they are trying to collect and we are informing patients of their balance and asking if they want to make a payment of $5 on the account. Some of these people have been ordering for years and are just now being told that they owe the money. Even if they don't pay, we still send out their supplies. I know this is illegal but I don't know who to go to.

    • Deni Edwards profile image
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      Deni Edwards 5 years ago from california

      Victoria! Wow! This is quite a story here.

      I've pretty much outlined what you need to do in the article. If I were you, I would get in touch with your local FBI office and ask to speak with the agent who works in Medicare Fraud and Abuse Department.

      You could also opt to find an attorney who handles Qui Tam (whistleblower) lawsuits prior to consulting the FBI. By doing this, you would be eligible to receive part of any recovery or settlement that your doc makes with the government. It is important to realize that only one person can be a whistleblower, so you are unable to tell the new employee about this if you decide to go this route. If, however, you choose to just contact the FBI, you both could do this. It would be great because you have the knowledge and the new employee will still be working there so she will be able to obtain documents from the office and anything else they need to begin their investigation.

      You could contact the fraud and abuse hotline for Medicare--but I wouldn't recommend going this route. Think of it like talking to a CSR at an insurance company. You need to go to an attorney or the FBI.

      Understand that with Medicare--this is a felony! The FBI, an attorney and the fraud and abuse department would want to know an estimate of how much money the doctor is making from all of his activities regarding the government claims (I can't find the right word to describe what he is doing--fraud--but very interesting fraud).

      With other insurance companies, like BCBS and others, they all have fraud and abuse departments that you can speak with--and you can turn him in that way to those insurance companies. I would definitely do this. Your doc will be knocked off the provider lists and be audited from every side by every insurance company.

      Yes, you can get into trouble for doing the things you have done, and this is why you must report him. The government will not go after cooperating witnesses or whistleblowers. He's going to get caught eventually, and you need to be the one to ensure it happens sooner rather than later, and that you are the one who turns him in--to protect yourself, too.

      Your nondisclosure statement does not apply here. When your doc commits a crime, there is nothing to worry about. You will not be prosecuted by the government or anyone else for saying anything to the authorities or an attorney. You would not be in trouble for taking documents, either, as long as it is for the purposes of giving information to authorities.

      While your doc and his attorney may be able to bully an employee who claims sexual harassment quite easily, it's going to be the other way around when they deal with the government.

      I also agree that he is in violation of HIPAA. This can all be nipped in the bud once you turn him in, and it is a given that he is going to have to deal with the consequences of his violations at the same time he deals with his investigations for fraud.

      If you would like to contact me further, please feel free to do so. Or just keep me posted on the comment section of the hub if you would like. This comment section has been a great documentation of how common fraud is and how hard it is for the employees who have to work for these criminals who are so very selfish and greedy.

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      Victoria 5 years ago

      I was recently the Office Manager for a Chiropractic Office - my last day being this very Wednesday - and I trained my replacement. Yet, I am really questioning what takes place in this office, as I think it is fraudulent and I do not want myself or the replacement to get in trouble for HIPAA violations or billing fraud. The Chiropractor is currently involved in an insurance investigation due to insurance fraud which a previous "partner" performed the so called fraud. Yet the Chiropractor admitted to me that he KNEW they changed his SOAP notes in order to bill for more money. He also has us bill for codes for patients which we NEVER saw in the office and he claims he see's at their place of employment or after work. My replacement, who has never worked in an office before in her life, called me today and said that the Chiropractor told her to bill yesterday for services he had not performed on patients that were not seen in the office, stating that he would see them on his way home. He also makes copies of patient information and carries it with him for reasons unknown - and recently he left this information at his girlfriends house. He bills Medicare and BCBS and other insurance companies when he has never completed the SOAP or Care Records for these patients. Upon starting in the office he was billing insurance companies for charts he does not even have any longer.However, he was billing for previous dates of service in which the patients were supposedly seen in his office. Yet, when you look back in his scheduling book it does not show that they have ever been in the office on those dates. He claims that it was on a computer system that was stolen. He uses templates for his SOAP notes and does NOT write the SOAP's himself - but rather gives a number for each and the Office Manager is expected to look it up on a template and write it out or copy and paste the information. He has charts in his office that have not had a care record completed in months, possibly even a year. He also keep confidential patient information on his laptop, which is used as the office computer since he does NOT have an office computer and he carries this with him where ever he goes and even leaves it in his car where it can be stolen. He has had myself and my replacement create initial exams and interim reports from his "memory", not from notes taken, and we may be creating them for dates back in May of 2011. He requires our Massage Therapist, who are 1099 sub-contractors, to wait around the office on possible walk-in massage appointments, but does NOT pay them for their time unless they do a massage. During one afternoon when I was sick and unable to enter the office, I received a call from the office and it was not the doctor on the other end but one of our patients. I was informed that the patient owed the doctor a favor and was in helping work on other patients claims and help run the office for the day. Is this not a HIPAA violation?

      I am wondering if my replacement and myself are in possible danger of getting in trouble ourselves? And can I legally report this information even if I signed an Employment Application that informs a nondisclosure statement?

      If I do report should I report directly to the insurance carriers and adjusters of the patients that are involved, as well as the insurance investigation group who is already investigating his partner and the offices actions? Should I report directly to Medicare and BCBS?

      Any and ALL guidance would be helpful as I do not want my self or my replacement to get in any kind of trouble. Also I am a bit nervous as to what will happen because the previous Office Manager filed a Sexual Harassment suit against him and he and his attorney have bullied her into dropping it.

    • Deni Edwards profile image
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      Deni Edwards 5 years ago from california

      You can't bill for services that haven't been performed. If the bill is going out as global, when the global procedure has not been performed, it is considered a falsified document.

      Two choices: the office reverts back to the way it had billed out previously--by waiting for the interpretation. Or, if they do not wait for the interpretation, then two separate bills must be submitted broken down by components (or submitting one bill with two dates of service and broken down into separate components). These are the only two choices.

      The bill should not be going out as global when, in fact, that service has not been performed.

      As far as getting into trouble, I can't really say. If the doc is ever audited, it might be something that would be discovered and, possibly, be reprimanded for.

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      Jennifer 5 years ago

      Thank you for the detailed answer. My office is still global billing without the interpretation. Could we be in trouble for this or is it just frowned upon?

    • Deni Edwards profile image
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      Deni Edwards 5 years ago from california

      The reason the billing was not being done prior to the doctor's interpretation was so the procedure could be billed as a global procedure (technical and professional component). If the procedure is now being billed prior to the reading/interpretation of the report, the procedure code (CPT code) needs to be billed with a TC now and then later with a modifier -26 reflecting the interpretation. The modifier -26 would be billing for the interpretation(physician), while the TC component would be billing for the ultrasound--technical component.

      So, it would be easier to revert back to the old way of doing the billing--waiting for the entire procedure to be done (test and interpretation).

      If the bill is not being broken down into two parts, and it is being billed as a global procedure when the docs have not yet, in fact, interpreted it, this could cause problems, and yes you are right that they should not be doing it this way. Documentation (the reading and interpretation) must be included to bill for the global procedure.

      I would just verify what code is being used. If the bill is going out prior to interpretation, the cpt code with a modifier TC must be used. If it isn't being used, again, they should break it up or revert to the old way of doing things (which is more efficient and correct procedure).

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      Jennifer 5 years ago

      I work at an OB office with three doctors. We have a tech who performs ultrasound scans on our patients in the office. We are now billing for the tests before the doctor looks at them or reads them. We used to wait for the doctor's report to be ready before we could bill. Is this allowed?

    • Deni Edwards profile image
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      Deni Edwards 5 years ago from california

      I'm quite shocked, actually, that you have been performing the x-rays more than anything else you've mentioned. Shady billing practices, on the other hand, I'm sort of used to because it occurs so often.

      There are a multitude of reasons that only trained and qualified people perform x-rays, and probably the most important is the health and safety of both the x-ray tech and the patient. So, I'm floored. Your doc is putting people's (including your own) health at risk.

      I can only say what I would do in your situation since I am pretty cut and dry. I would answer all the questions honestly (with a smile on my face because of their threat and because they put my health on the line), and consult with an employment attorney ASAP. These attorneys are free because they take cases on a contingent basis.

      You have other options, if you don't want to come clean, and I've outlined them above, to include an anonymous complaint as specific as possible. Understand, however, cases reported anonymously are put at the bottom of the list.

      You could also opt to call the person who comes in to audit your doc after the visit and explain why you couldn't come forward and tell the truth at that point.

      Keep in mind that since you are not licensed to perform x-rays, and the fact that you are aware of this, too, could make you liable for anything that occurs--like exposure. This is just an all-around terrible situation. Again, if it were me, I'd nip this problem in the bud immediately. This is uncalled for.

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      Joe Shmow 5 years ago

      I currently work for a podiatrist. In the office he has quite a bit of diagnostic equipment including a x-ray machine; as his medical assistant I perform all of his testing including x-rays(which I am not certified to do, I checked with my state rules for "scope of practice"). Just recently we were notified of a state inspection up and comming. I was told to lie and state, when asked who takes all the x-rays. That "Dr. So and so" takes all the x-rays. I was told this so the office may pass the state inspection! And so he can bill as though he took them. Also, there is in office form of physical thearpy done via machine that according to the new insurance regualtions the Dr. must not only hook the pt. up; but set all the settings to bill corectly. As I am sure he is billing as though he "hooked the pt. up. Although I and other staff members are doing so. I have been told to "cooperate" or "Things will not go well for you, my friend". Sounds like a threat to fire me; by the I see it. An audit would reveal that he would not have time to perform all of the "Testing and services" for which he is billing. What can I do? If I go to him and convay my thoughts, feeling, and display my level of knowledge he will fire me! Any advice would be greatly apprecitated.

    • Deni Edwards profile image
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      Deni Edwards 5 years ago from california

      I would really suggest contacting your local FBI office and request to speak with the fraud and abuse department.

      Or

      Find an attorney, either one who specializes in employment law or qui tam/false claims

      Or

      Do both.

      I'm sorry to hear about this. It's very stressful. Hang in there, but be sure to follow up with doing the right thing despite it being so difficult.

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      Chad 5 years ago

      I work for a private ambulance service and I have been pressed by higher up employees to "play ball" or adapt into the "grey" or leave things out on my reports on order for Medicare to pay on them. Or "add a pay line" in the report. I am now on the verge of getting fired bc I will not lie or leave things out on my report. If a patient doesn't qualify then it's not my job to make them qualify. I'm there to give care to the patient during the time I take over care to the time I turn over care to another person higher ranking then myself. I was taught to document everything I see and how I see it bc it is MY report. This company wants me to write reports in order for them to get paid and now that I refuse to do so, termination is put out there. I've also suspected the company of double billing but I have no proof. Most of these companies in Houston are nothing but crooks. I thought my company was legit but now I have been proved wrong. How do I go about turning the company in etc? He's already fired people for the same thing so I'm sure my day is coming soon. Thanks

    • Deni Edwards profile image
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      Deni Edwards 5 years ago from california

      I would have to agree with you, and including the dental billing, too--chiropractic care, too.

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      Sally Nameless 5 years ago

      This stuff happens ALL the TIME in the healthcare industry! Especially with the recession!!!! If there is anyone out there that thinks that they know of a situation where this is true, "that if the government, etc knew what this or that doctor was doing they would shut down the practice" they are NOT ALONE! I've been in the dental field for over 20 years and have done substitute work for the last 12 years so I've worked in MANY various offices. I can assure you that over 65-70% of these offices submit fraudulent claims! And MUCH more than 1 or 2 a day!!! Dentists who take HMO patients do this routinely since they make "ZIP", hardly ANYTHING at all on HMO patients! So they will bill out unnecessary "necessary" procedures to make up for the loss. Also, beware peeps...if you have an HMO and your hygienist spends less than 35-40 mins for your cleaning appt. you can BET that you are NOT receiving the cleaning that is SUPPOSED to be done! I routinely see HMO patients who have BLACK tartar buildup underneath their gumline. That means that it has been there for a VERY LONG TIME...YEARS and YEARS, and no one has bothered to remove it because THAT takes work and TIME! Work and time is NOT what you get when you are an HMO dental patient, in general. They want to get you in and OUT of the chair as fast as they can to make room for "Profitable", PPO patients! This is sad but the simple Truth! I can say this now b/c I no longer work with one employer. I just do substitute work; I help out on a last minute basis when a hygienist is sick, etc. So, the TRUTH is easy for me! Believe it!!!

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      Deni Edwards 6 years ago from california

      Hi, Stephenee,

      The answer is yes. There have been cases where employees, commonly office managers and co-conspirators, have been prosecuted, fined, and have served jail time in addition to the provider.

      I am sorry that you are having to deal with this situation, but this is one of the reasons why I have written this article. You really should take the necessary steps to report your employer. Here is some information in addition to the article on how to report fraud--some is a repeat:

      By Phone: 1-800-HHS-TIPS (1-800-447-8477)

      By Fax: 1-800-223-2164

      (no more than 10 pages please)

      By E-Mail: HHSTips@oig.hhs.gov

      By Mail: Office of the Inspector General

      HHS TIPS Hotline

      P.O. Box 23489

      Washington, DC 20026

      Do yourself a favor and report the provider. You will feel better about yourself. Understand that your employer is not only taking advantage of seniors who have to pay cash for part of these services and ripping of taxpayers, your employer is forcing you to commit a felony.

      I would urge you to make the right decision and report this case. Good luck.

    • profile image

      Stephenee 6 years ago

      My boss is creating medicare notes by backdating the electronic program and entering history and treatment goal, along with daily notes that were not kept originally. We are in a Cert audit and we are a chiropractic office where some patients were seen up to 50 times per year. we have been told to help enter this information and we want to know if we can get into trouble.

    • Deni Edwards profile image
      Author

      Deni Edwards 6 years ago from california

      Sally,

      Although I understand your frustration, you indicate that honest people are the ones suffering most; however, your friend is not honest. It doesn't matter that she has a job to lose or not, and, no, it doesn't seem as if it is a good job if what you say is true.

      Understand that the government is recouping money and investigating cases of fraud all the time. Priority cases would be cases where the government has evidence (either by an audit or a cooperating witness), and your information is entirely based upon "my friend says".

      That said, I would suggest contacting Medicare and speaking with someone, giving them all information that you are aware of and hope that Medicare will do an audit. That is the right thing for you to do. The right thing for your friend to do is gather evidence and turn her employer in.

    • profile image

      sally 6 years ago

      OK, but I'm not the one considering reporting and don't have access to any documents. I know someone who manages an office that provides physical therapy services. My friend told me "if medicare were to do an audit, they would shut down our business". I hear a lot of talk from this person on the different ways these practices affect their ability to run a legitimate business - and how frustrating it is for her.

      I feel like doing something about it. She won't...she has a job to lose. A good job.

      It makes me angry! So, you're telling me if I provide you with a company name, address, phone...you probably won't investigate?? Great - no wonder medical costs are soaring in the country and the honest people are the ones who are suffering the most. Lovely