corporate compliance

Nurses General Nursing

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Anyone have any experience with reporting medicare fraud? need advice NOW

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Specializes in Med surg, LTC, Administration.

Just call your BON and fire away. Peace!

Unless you want to elaborate...

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Specializes in ED, ICU, MS/MT, PCU, CM, House Sup, Frontline mgr.

your facility, especially if it receives medicare and medicaid payments, should have a compliance officer. if you do not have one, then you should have been oriented to the phone number you can use in case of fraud. if not, that is a big no-no. google medicare and medicaid payment fraud for your state to get in touch with local officials. gl!

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If fraud is reported, and there is an investigation initiated, is the employee "safe" since they did notify. What do you do in the mean time? Business as usual?

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If fraud is reported, and there is an investigation initiated, is the employee "safe" since they did notify. What do you do in the mean time? Business as usual?

surely they have a way to report anonymously posted in the workplace??

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If fraud is reported, and there is an investigation initiated, is the employee "safe" since they did notify. What do you do in the mean time? Business as usual?

surely they have a way to report anonymously posted in the workplace??

I think she may be referring to the the fact that she is possibly privy to the knowledge of or either an unwilling participant in fraudulent behavior. Wondering what the impact will be on her upon federal investigation.

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I think she may be referring to the the fact that she is possibly privy to the knowledge of or either an unwilling participant in fraudulent behavior. Wondering what the impact will be on her upon federal investigation.

You may be correct however, I don't want to assume...Hence the post/suggestion. Tough situation to be in, for sure......

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If fraud is reported, and there is an investigation initiated, is the employee "safe" since they did notify. What do you do in the mean time? Business as usual?

Google whistleblowing

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Specializes in Functional Medicine, Holistic Nutrition.
Anyone have any experience with reporting medicare fraud? need advice NOW

There are some cases where, unfortunately, reporting the issue to the compliance officer may not resolve this issue. In that case, you have several options. One is the report to the federal Office of Inspector General: http://oig.hhs.gov/fraud/hotline/ . They do take anonymous complaints. If your organization is accredited, you should also report it to the accreditating organization (Joint Commission, CHAP, etc.). Finally, you should also report the issue to the State. Every state is different, but it would typically NOT be the board of nursing, as another poster suggested. It will the state agency that accredits or licenses the facility: the Department of Community Health, etc.

Good luck and let me know if you have any other questions.

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Specializes in ER, ICU.

Whistleblowing laws vary by state. Make sure you don't do anything, like violate confidentiality, which could get you fired or put you on the other side of the law. Good luck and thanks for doing the right thing.

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Specializes in Hospice.

If you are uncomfortable with a report to your own corporate compliance officer, then go directly to medicare:

http://www.medicare.gov/navigation/help-and-support/fraud-and-abuse/fraud-and-abuse-overview.aspx

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Specializes in Flight, ER, Transport, ICU/Critical Care.

This is one tough area to navigate. Be cautious and very certain of where you stand in the issue.

I'd be unlikely to report to corporate because you will be caught in it and if there is badness there or not - there is no upside for you. CMS has a direct contact on their webpage for FRAUD reporting - but I'd get an attorney to advise me BEFORE I do anything.

Any organization will do WHATEVER it takes to defend itself and S&!$ rolls downhill - so, be SURE that you can get caught in it.

CMS rules are complicated and just because a provider is "doing something" questionable may not mean they are billing for it in a way that may violate standards as they relate to money.

Clinical standards vs. reimbursement practices can get tricky. I've seen some wicked questionable clinical decisions and practices that DO NOT translate to medicare fraud. And I have seen other cases where "stuff" is being done in a questionable manner and those employed just go along, because they it is "how things are done". There are any number of tough spots in between. Example: A provider provides a clinical service and either manipulates the clinical "presentation" or pencil-whips the record to make it look a more complex case than it is (or was) and then bills CMS requesting a rate of reimbursement not truly supported clinically - medicare fraud perhaps, but really hard to report without the one reporting having enough intimate knowledge to make the reporter's involvement questionable.

If this is, in fact, related to money matters and you can divulge WITHOUT violating any confidential info - proceed with caution. I'd hate to see good intentions take you down...

If you can proceed and "want to eat lunch in this town again" (keep any chance of working - for anyone) I'd think it wise to retain experienced counsel with experience in CMS regulations and "whistleblower" protections. If you report fraud and they find it - there is an economic "incentive" for the one that reports it to be reimbursed a % of what they (CMS) recovers --- so, an attorney may be willing to take the case on that term.

Good Luck.

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