Fraud? Should I report?

[MotoRN34]

Hey guys I'll keep this short. I work for a HHA and a co-worker submitted documentation to get paid for visits she did not do. She even forged patient's signatures. What's even more interesting is that she was caught by the manager. However, she was not fired and there were no disciplinary actions taken. Should I report this?

[caliotter3]

Consider the ramifications of creating problems for your former employer (and they will be your former employer) and decide whether or not you want to take the risk to your own future employment. Former employers have an eery ability to successfully blacklist former employees whether or not the employee was at fault for anything. No matter your decision, if it were me, I think I would make plans to find a new job. There is a limit to employer behavior that one should have to endure on a day to day basis. Who wants to be around anyway when the stuff hits the fan should this employer find itself in hot water with regulatory agencies whether or not it is you that is the direct cause.

[totallackofsurprise]

Hate to sound like a cynic, but that old adage applies: "If you see something you do not understand, look for the financial interest."

The manager doesn't care because

1) the agency gets paid regardless of whether or not the visits actually occur. Medicare or other insurance already pre-approved 9 weeks of visits or however much the patient could get.

That's a gravy train no manager will mess with, if they want to keep their job. Remember: whatever you get paid per visit, the HH agency charges 3-4x that to insurance companies. That's a lot of $ -- which they won't get paid for each visit she didn't make. They aren't going to give that up.

2) If the manager does anything, the fraud also has to be reported to the appropriate state and federal authorities. This results in greatly increased scrutiny of the HH agency... sometimes for months or years. The HH agency doesn't want that at all.

Unless the patient/patient's family calls Medicare/private insurance to report that the HH RN isn't showing up, no one will know. If there is a language &/or literacy barrier with the patient/family? They will never call. And it will go unreported. And the agency gets paid like they were going to anyway -- whether she visited the patient, or not. The manager and upper admin of the HH agency know this.

Also, now that they did nothing to her, your fraudulent coworker knows they looked the other way -- essentially, they condoned/co-signed her fraud. If they try to discipline her in any way now, she could retaliate and report the HH agency for fraud... and again, the HH agency is under the microscope. But she'll be gone; it won't affect her.

More than likely, though, your coworker is not the only person doing this, or management sort of gave her the idea. I've only been doing HH for 5 months (after 6 years at my previous hospital job, 12 years total as an RN)... and for a variety of reasons, I am looking for another FT hospital job.

Mainly it's about HH's lousy pay (and unreimbursed mileage, and all the unpaid charting time). But I have already seen some hinky things in the short time I've been doing it. Fudging of dates. People told to chart that they did a procedure they not only didn't do, but didn't do because the MD's HH orders expressly said not to do. Again, it's the financial interest: They can bill extra for certain procedures.

So based on my short time in HH, I think it is probably as susceptible to insurance fraud as any hospital or clinic -- if not more.

Now, if you feel conscience bound to report this, and I don't blame you if you do, you're going to have to be patient AND careful. You must get the names and minimally the DOBs of the patients she didn't visit but for which the agency billed, and then

1) find another job and leave this HH agency, then

2) wait some weeks or months to report what you saw, so that the agency won't immediately suspect you were the whistleblower. (Which they might if state and insurance regulators are suddenly breathing down their necks right after you leave the agency).

#2 is important to protect yourself. Even in big cities, healthcare can be a small world. If the HH agency thinks you blew the whistle, they may throw you under the bus and try to get you blacklisted. I know that sounds paranoid, but you have to protect yourself even as you try to do the right thing.

[Matikins RN, BSN]

I have served in different roles within a home health setting to consist of RN Field nurse, Case Manager, DON, and Administrator.

If we look torward the ANA code of ethics - and even your states respective board of nursing. We as nurses have a duty to report . In the above case patients quality of care is being jeporadized and the client is being put at risk for serious adverse events/ potential harm.

You can make a report anonymously to the certifying body that grants the home health a license to operate. That group would then send a surveyor to determine if allegations of fraud are true. We live in a generation where widespread fraud is rampant and CMS is cracking down on home healths and hospice providers. It is troubling to see that both the nurse and respective manager are setting the wrong example.

I would wait a little bit and let some time pass before filing the report. Employers do all kinds of things these days especially with blacklisting. I would also start looking at other jobs and opportunities to be ahead of the game just in case.

[carti, BSN, RN]

mind your own business. If it doesn't affect you at any way, don't worry about another man's (or woman's) pockets.

Why would you report anything? what good could possibly happen? Nothing