Has anyone ever reported SSI fraud on a patient?

redhead_NURSE98!, ADN, BSN · May 20, 2013

I do get rather tired of seeing that the patient is divorced and lives with their ex-spouse. It's pretty tiring to bust butt 13-14 hours a day for people who spend more time defrauding the system than it would take to make an honest living.

LadyFree28, BSN, LPN, RN · May 20, 2013

OP, here is the link to SSA office if inspector general, in terms of what they investigate:

http://oig.ssa.gov/what-abuse-fraud-and-waste

As far as reporting allegations of fraud from a federal program, that IS reportable; however, that doesn't mean they are commuting said "fraud"; it is NOT a crime to receive benefits with other people living in the home; they can be considered as separate households, even the ex-husbands or whomever living in the home-unless we are a fly on the wall and can hear EVERYTHING, or it comes from someone who is mad at that person and reports it, risking prosecution or a deal for committing a federal crime-there is no way one can infer they are committing "fraud" off of Medicare or Medicaid. My mother worked on a project for our state's attorney general office which oversee Medicaid and SSI fraud before she retired; she still is in contact with her other co-workers that still work there. Most cases were based on cash assistance and SSI-supplemental security income-which is funded by the state; social security cases such as SSDI -supplemental security disability income-and Medicare are handled by the SSA. They will investigate. This information is based on the state I am in; however, utilize the link and contact the state you are in if you wish to report.

SSI and SSDI have two different qualifications; someone who is disabled can qualify for both depending on the illness, and if qualified for both, they can ONLY collect one. In receiving benefits, you can STILL work; one is considered a disabled worker and can continue to work in order to make ends meet, ESPECIALLY if they have a mortgage or rent...being on a federal program DOES NOT necessarily mean a free ride if you still have co-pays (Medicare is charging pt's who go to ERs now in my state if they don't go into inpatient in my state) utilities, pay for food, dry goods( like soap and tooth paste and toilet tissue) and still have to pay for 20% of you health bills or medicine or Medigap insurance (Medicare)...those things still cost MONEY...it is no free ride. The requirement for working is that you make a minimum amount monthly; if you go over, the money is deducted from the check. The money is certainly not enough to live off of, it's peanuts-TRUST me...unless you get wavers for catastrophic coverage-which is another round of paperwork and a headache-to get help with the cost of medicines or coverage for healthcare.

Having SSI or SSDI is no walk in the park, or a scheme; it is a RIGOROUS process to get approved; most people do not get approved the first time around, and they do investigate and keep tabs. You have to resubmit every 2-3 years, even if you are over 50% disabled...they are very serious about Medicare fraud. If one can work or want to work, they do help with securing a job and going back to school, a bright spot for the many who are disabled and WANT to work and continue their livelihood, and most disabled workers are having an EXTREMELY hard time getting a job, or maintaing a job, especially if you are upfront in having a disability-I know this from MY experience and ask anyone here who has a disability. As well as pay...it is close to sometimes a no-win situation if you have to collect disability and get a below wage job close to poverty...you hope to keep you head above water and not contribute to the national debt by trying to pay your bills pre-disability.

OK...off my soapbox now. :)

I saw a program YEARS ago where this man was embezzling the government in social security disability income, and few other sources of income; his wife and the man would travel to the Philippines and had an offshore operation. When they attempted to reenter the US; customs stopped them for having like over 50 grand...they called SSA and they had investigated them for YEARS before they charged them...but that's a huge red flag case.

Another case: a doctor whose care I was under when I had been in a car accident when I went to physical therapy had committed SSDI fraud by signing off on examinations for visas for people who needed work; instead he, with an immigration lawyer, signed off on numerous SSDI and SSI, netting the immigration lawyer thousands of dollars and benefits to people who bypassed the immigration process; however, some of the social security numbers were other people's numbers (just like the example that another poster commented on). The red flag came up, investigated for YEARS, and the doctor said he was "only helping the individuals" and agreed to assist the Feds. He had to give up his license. It was a surprise to me, and I'm sure at the office. I can only say he was a good physician, and he respected that I was a nurse and worked with my recovery-and this was my second car accident in 6 months, but I digress...he still committed fraud, but he knew what he was doing as far as my care after my accident.

So to OP-by all means report your suspicions to SSA, and let them handle the investigation. If the person you suspect is committing the fraud, they will be prosecuted. You certainly have nothing to lose by reporting; nor is it a HIPPA violation; SSA is given consent by the individual when they report their disability.

Mulan · May 20, 2013

but, so is condoning fraud.

and stolen social security numbers, identify theft

Mulan · May 20, 2013

It's usually considered poor form to take advantage of the relationship you develop with a patient to report them to authorities. If a patient confided in you that they smoke pot, would you then report them to authorities? Aside from mandatory reportable issues and imminent risk of harm to the patient or others, reporting an SSI issue or other information that patient should assume is confidential is arguably poor Nursing ethics.

I bet you'd feel differently if it was your social security number that was being used.

Mulan · May 20, 2013

I know I see it all the time, and it is starting to get ridiculous. I am nervous about reporting patients due to providing too much information that would violate HIPPA. Need advise and input on reporting SSI fraud on patients!

anonymously

MunoRN, RN · May 20, 2013

Mulan, I realize it can be frustrating but it's part of our Code of Ethics, it's actually common to many Health Care professions' code of ethics including Doctors, Psychiatrists, and others. The Nurse/Patient open and trusting communication relationship is a basic premise of our profession, if that's not something you can uphold maybe it would be wise to consider a Nursing role where you have to deal with such challenges.

Esme12, ASN, BSN, RN · May 20, 2013

I know I see it all the time, and it is starting to get ridiculous. I am nervous about reporting patients due to providing too much information that would violate HIPPA. Need advise and input on reporting SSI fraud on patients!

First it's HIPAA NOT HIPPA....sorry pet peeve.

We cannot offer legal advice.....there is not mandated SSI/SSDI fraud reporting so you aren't obligated by law. There is some patient nurse confidentiality at stake here....privileged information and all...however that is usually disregarded where a crime has been committed. You say patients...so that is pleural I know fraud is rampant but you nerd to be very sure before you disrupt their lives and play with their livelihood.

Is it your place to report?..only your conscience will anser that for sure. Is it HIPAA..?....you need to ask a lawyer.

morte, LPN, LVN · May 20, 2013

I am not so sure that the feds would agree on the "not mandated to report", when it is "their" money being stolen. I put "their" in quotes, because, really, it is OURS! If it can be proven we knew, does that not make us guilty of collusion?

First it's HIPAA NOT HIPPA....sorry pet peeve.
We cannot offer legal advice.....there is not mandated SSI/SSDI fraud reporting so you aren't obligated by law. There is some patient nurse confidentiality at stake here....privileged information and all...however that is usually disregarded where a crime has been committed. You say patients...so that is pleural I know fraud is rampant but you nerd to be very sure before you disrupt their lives and play with their livelihood.
Is it your place to report?..only your conscience will anser that for sure. Is it HIPAA..?....you need to ask a lawyer.

Esme12, ASN, BSN, RN · May 20, 2013

I am not so sure that the feds would agree on the "not mandated to report", when it is "their" money being stolen. I put "their" in quotes, because, really, it is OURS! If it can be proven we knew, does that not make us guilty of collusion?

I 150% agree, however it isn't a law mandated like child abuse is what I mean by "mandated". I am not going to debate being guilty of collusion

\Col*lu"sion\, n. [L. collusio: cf. F. collusion. See {Collude}.] 1. A secret agreement and cooperation for a fraudulent or deceitful purpose; a playing into each other's hands; deceit; fraud; cunning.

for no agreement has been for it implies intent and not suspicion of wrong doing becasue of access to certain confidential documents. That is something a lawyer can answer and is off topic

To the OP's question I am just saying they need to be very sure before they accuse people of wrong doing.

Calabria, BSN, RN · May 20, 2013

I have. The patient gave us two names, first of all. Then, admitting came to see the patient, and something didn't add up when she asked for the patient's ID.

We called our manager, who called risk management and compliance, who advised us to call our campus' police force. They straightened it out and got the situation corrected for us. No charges were filed.

Sadala, ADN, RN · May 20, 2013

It's usually considered poor form to take advantage of the relationship you develop with a patient to report them to authorities. If a patient confided in you that they smoke pot, would you then report them to authorities? Aside from mandatory reportable issues and imminent risk of harm to the patient or others, reporting an SSI issue or other information that patient should assume is confidential is arguably poor Nursing ethics.

Completely agreed. And I'm not even sure that it's allowable except in the case where you are a mandatory reporter (suspected child, elder, disabled abuse for instance).

Sadala, ADN, RN · May 20, 2013

Decent guide here: http://www.medscape.org/viewarticle/585562_2

Some things vary state to state apparently, such as whether or not domestic violence or assault must/can be reported to law enforcement without the pt's consent. Not really seeing anything about pt fraud or other financial crime.

I think that the mandatory laws provide the only coverage for health practitioners in terms of hipaa (could be wrong, but that's how I read it) - usually comprised of safety issues, such as gunshot wounds, impaired ability to drive, abuse and neglect, danger to self or others, certain infectious diseases, certain healthcare errors/misconduct in pt care, that sort of thing.

That said, I know that there have been criminal cases involving one pt using another's insurance. I don't know if any of these cases has occurred following the enactment of hipaa. But I do distinctly remember one case where a young man fell down a cliff, and his friend (with him at the time) switched identities and insurance with him and they both later were criminally convicted. Not so sure how that came to light with authorities.

Will prob research it a bit.

I don't really like the idea (personally) of departing from my role as pt advocate except in cases of abuse/neglect, etc. Then my conscience allows (in the case of children/elderly/disabled) or in order to protect the public (depending on the situation). I would even feel uncomfortable with a state law for mandatory reporting of rape/assault/domestic violence without the victim's permission. Seems it might have a chilling effect on those who wish to seek care.