About three months ago, I started work as a staff RN at an adult day health center. While completing patient assessments that I was assigned, I unintentionally uncovered signs that my employer is committing fraud. Patients' ADL sheets are being completed for days that they are not in attendance at the center. Patients' care needs are being exaggerated on MDS assesments and in ADL documentation. After noticing these trends in a couple of patient charts, I did a little digging and discovered that the problem is widespread throughout the facility.
How do I approach this dilemma? The way I see it, I have three options:
1. Continue working there and pretend that I haven't noticed the fraud. Enjoy the great working hours, reasonable pay, and the friendships that I've made. Continue to be accurate in my own documentation.
2. Leave my job. Then, report the fraud. I feel this is more ethical than option 1. However, I am concerned about many people losing their jobs and many patients losing needed services if the business is fined heavily or shut down. I am also somewhat afraid of retribution.
3. Leave my job and never mention the fraud to anyone.
4. Remain at my job and speak openly with the employer, letting them know that I am aware of what is taking place, and that I am not okay with it. I can't predict what would result from taking this route.
I would like to know if anyone else has experienced this dilemma. Are there options available to me that I haven't considered? What would you do in this situation? I appreciate any advice, info, or stories. Am I over-reacting? Is this common in health care?
Specializes in Psychiatric nursing; Medical-Surgrical.
About three months ago, I started work as a staff RN at an adult day health center. While completing patient assessments that I was assigned, I unintentionally uncovered signs that my employer is committing fraud. Patients' ADL sheets are being completed for days that they are not in attendance at the center. Patients' care needs are being exaggerated on MDS assesments and in ADL documentation. After noticing these trends in a couple of patient charts, I did a little digging and discovered that the problem is widespread throughout the facility.
How do I approach this dilemma? The way I see it, I have three options:
1. Continue working there and pretend that I haven't noticed the fraud. Enjoy the great working hours, reasonable pay, and the friendships that I've made. Continue to be accurate in my own documentation.
2. Leave my job. Then, report the fraud. I feel this is more ethical than option 1. However, I am concerned about many people losing their jobs and many patients losing needed services if the business is fined heavily or shut down. I am also somewhat afraid of retribution.
3. Leave my job and never mention the fraud to anyone.
4. Remain at my job and speak openly with the employer, letting them know that I am aware of what is taking place, and that I am not okay with it. I can't predict what would result from taking this route.
I would like to know if anyone else has experienced this dilemma. Are there options available to me that I haven't considered? What would you do in this situation? I appreciate any advice, info, or stories. Am I over-reacting? Is this common in health care?
Please help!
Girl🤔report the medical fraud get your rewards and be rich[emoji1]. Save yourself and your licence too.
Thank you all so much! Now I'm sure I wasn't overreacting. I'm so grateful for you guys! I really didn't have anyone else to talk to about this. Now I know what I have to do....
Adult day health care is a supervised daytime program providing skilled nursing and rehabilitative therapy services in addition to personal care services. Adult day health care services are appropriate for adults with medical or disabling conditions that require the intervention or services of a registered nurse (RN) or licensed rehabilitative therapist acting under the supervision of the client's physician.
This is a program that is being paid for by public/state funded insurance. Which is usually the most vulnerable of the population. Which is a huge risk factor patient population. Akin to collecting Grandpa's social security check as one is a "caregiver" that just lives in the house for free and Grandpa gets no care.
I would be very concerned that the people who are supposed to be there are not, and what kind of quality care they are receiving. Unethical for sure. And I am sure there's a process for checking on people who are supposed to be there, but are not. And no one is completing that process but instead false documenting? Huge red flags for the licensing and/or regulatory body who will audit the charts. Not to mention the weird stuff....for instance, say the person was admitted to the hospital. So the hospital and the care facility is billing for the same day? How could that be? And interestingly, this stuff comes up as flagged more often than one would think.
And as I understand it, if you are signed off on any part of a chart that is fraudulent, nurses can be "banned" from working for any facility that accepts any type of governmental insurance...which is just about anywhere...
Be very prepared to discuss why you sign off on charts where you know there is fraud. This is a mess for you and your career. If you have malpractice insurance (and you should) I would contact them for advice.
The process is similar. The OP needs to contact the regulatory agency for the program AFTER she quits her job though. No matter what one is told in a small company or unit management usually figures out who blew the whistle.
OP gather as much supporting data as you can without violating HIPAA and find another job ASAP. Then report to the regulatory agency and let them do their job of investigation. It is these types of practices that make it easy for lawmakers to cut Medicaid reimbursements and impose draconian documentation requirements that hinder or even prevent individuals who need the Medicaid funded services from receiving what is required for them to function appropriately. Fraud hurts not only the consumers needing it but all of us who work with these populations.
Just my two cents based on many years working in Medicaid waiver programs.
I have reported in past fraud with pics and evidence, nothing ever happen, it was about and individual, I wanted no reward or was aware of any type of reward. I submitted and nothing happened, It best to not waste your time trying to report it.
If it was me and I was sure fraud was being committed I would be out looking for another job
Specializes in ER, ICU/CCU, Open Heart OR Recovery, Etc.
Get another job. Report this company to the Health and Human Services/Medicaid Division. Hire an attorney as well. It's just not worth ignoring. You'll go down like everyone else will if the wrongdoing is discovered and you didn't say anything. This will have serious recriminations on your nursing license if you don't address it and it is discovered as well.
Specializes in QA, ID/DD, Correctional, Education.
I have reported in past fraud with pics and evidence, nothing ever happen, it was about and individual, I wanted no reward or was aware of any type of reward. I submitted and nothing happened, It best to not waste your time trying to report it.
If it was me and I was sure fraud was being committed I would be out looking for another job
I do not know what state you live in or what the details were that you reported but I know personally that reporting inappropriate billing and neglect issues in my state does result in investigations. In one case where I left a job at the end of my shift without notice due to some truly outrageous conduct and false documentation done by my supervisor there was some substantial changes made after my reporting to the regulatory body about those actions.
Neither I nor anyone else can guarantee that an investigation will happen or if one does what the outcome may be but I can assure you that not reporting can have dire consequences if an audit reveals your name as the "sign off nurse" for billing, care documentation etc. Personally I would not be able to rest easy knowing I saw activities like this and did nothing but quit my job.
Ndy-RN
106 Posts
Girl🤔report the medical fraud get your rewards and be rich[emoji1]. Save yourself and your licence too.