Medicaid Fraud - Am I Liable??

[Nurse Beth, MSN]

Dear Nurse Beth,

I've just discovered that my employer is committing Medicaid fraud. I am an RN who is a fairly new employee of a small, privately owned adult day health center and I am not in a management position. While I was accessing patient records to complete required assessments, I noticed that MDS and Medicaid ADL documentation is incorrect. The inaccuracies appear to be intentional. The patient's care needs are clearly exaggerated and daily ADL documentation is being completed for patients on days in which they are not in attendance at the program. Thinking that the program aides are in need of some further education on documentation, I approached two with my findings. They each told me that they have been instructed to complete the documentation in this way. They are both aware that the documentation is incorrect, however they have been trained to do it this way.

I'm not sure what my ethical or legal responsibility is in this situation. My head is telling me that I should express my concerns to management and potentially report this activity. However, my heart is telling me that those actions could potentially put many people out of work and leave many elderly without needed services. I also fear retaliation from my employer.

I worry about what could potentially happen if I keep my mouth shut and the fraud is eventually uncovered. Could I be held personally liable?

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Dear Am I Liable,

First of all, it is unlikely that you would be implicated, as you didn't participate in the fraud offense. You are not billing misinformation, or receiving kickbacks, You are not in conspiracy to do so. To be safe, though it is best to separate yourself from an employer you know to be dishonest.

Do not report to your manager, as there is a chance they already are aware and you risk losing your job if that is the case. The agency to report to is the Department of Justice (DOJ).

Unfortunately fraud is rampant. There is a case where an agency had their Alzheimer's patients watch Forrest Gump” once a week. They then billed for group therapy.

Reporting and Rewards

The DOJ relies on and rewards healthcare professionals who report fraud. The DOJ provides job protection (whistleblower protection), and gives a portion of the money they recoup to the informant.

According to a Medicare Gov't website, you could be eligible for up to $1,000 dollars for reporting fraud and if at least $100.00 is recovered.

Retaliation

Even with whistleblower protection on the books, employers can retaliate in subtle ways that can make your work life very uncomfortable, with the goal of you quitting. It is difficult to bring charges against an employer and still work for them.

Ethics

You are in a tough position, because you are concerned about the loss of work for employees and loss of care for patients it could cause. by reporting.

The greater evil, however, is stealing from the government, and defrauding taxpayers as well as individuals who need services. Medicare and Medical fraud are one reason healthcare costs are so high.

I consulted with my sister as she is an MDS Director and nurse. Her advice is to look for another job, or to make peace with it and stay quiet until you can leave.

Best wishes,

Nurse Beth

[d'cm]

LIABLE, forget about reporting this fraud to the government. They are not interested unless it is mega millions and you can hand them the case on a silver platter. This is actually more an "abuse" rather than fraud because clinical eligibility is determined by the insurance, be it The State or MCO. And as a nurse who makes those assessments and determinations I can tell you that we pay no attention to those ADL checklists because everybody knows they are bull. MDC's usually get caught for fraud when they drop claims for days that member is not there. If your State is using MCO's to manage long term care services like MDC and PCA, you should consider working for the MCO.

[travduck, BSN, RN, CNM]

While possible that this nurse would not be implicated in the actual fraud, if discovered she could be charged with being an accessory after the fact. Besides reporting stat she can also consult the legal department of her BORN. Also - does she really want to abandon her patient to fraudulent caregivers who are willingly committing a breach of ethics. What other yuckie and anethical behavior are they engaging in. If facility is found out later then this nurse must live with the stain on her own reputation and ethics as she knew it was happening and did not report it.

[offlabel]

Leaves without reporting it, and it's discovered in the future and prosecution goes forward, she'll be in the position of proving she was not involved. She may be anyway as a whistle blower, but she won't even have that in her favor if she "makes peace with it". Awful advice. The folks who pursue Medicare fraud are ravenous junkyard dogs with little regard to anything else but getting a conviction.

I get that it's a contrived "letter" for the sake of discussion, but it happens in reality every day. Great caution is called for in a situation like that.

[heron, ASN, RN]

... The folks who pursue Medicare fraud are ravenous junkyard dogs with little regard to anything else but getting a conviction ...

Is this a bad thing?

[offlabel]

Is this a bad thing?

It is if you happen to be caught between them and the guilty parties. And you're not involved. Yes, I'd say that's a bad thing.

[DonnaAbate]

Hi All, In regards to this Medicare Fraud, I would look for another job and then report the incident to the proper authorities. Recently, on the news was a doctor in Michigan that was billing Medicare by giving patients unnecessary chemotherapy and some didn't even have cancer. There were several deaths as a result. One nurse that applied for a job at the facility reported it the first time and the state didn't bother much to investigate. Eventually, after many people became sick and died, the doctor was caught by a sheer coincidence.

Good luck to you and look for another job and then report it.