Medical doctors should be able to focus on providing the best possible care for their patients. However, in the complex world of healthcare, it’s not uncommon for doctors to inadvertently become entangled in fraudulent schemes they are unaware of, such as medical billing or coding fraud.

In this blog post, we’ll shed light on how physicians may unknowingly participate in fraudulent activities, the repercussions of such actions, the avenues for you to disclose the wrongdoing, and available protections for whistleblowers.

The Hidden Dilemma: Unwilling Participants in Fraud

While it is true that medical billing is primarily handled by administrative staff and billing professionals in most cases, it is also true that fraudulent activities can involve doctors in certain situations. Medical professionals may be pressured to provide inaccurate documentation or medical codes, which can lead to fraud and impact the entire billing process.

This can occur when upper management within an organization pressure doctors to engage in fraudulent activities under the risk of job retaliation. Some common medical billing fraud schemes that physicians may be forced to commit include:

  • Risk Adjustment Factor (RAF) Manipulation
  • Medical Loss Ratio (MLR) Manipulation
  • Phantom billing
  • Unbundling

Each of these actions occurs when services are billed or coded incorrectly in an attempt to increase profits. These actions can constitute healthcare fraud and may lead to serious legal consequences for both you and your employer.

Finding Your Way Out of Medical Billing Fraud

The realization that you might have inadvertently played a role in medical billing fraud can be disheartening and unsettling. It’s important to understand that such manipulation may not be of your own doing but rather the result of unscrupulous practices within your organization. If you find yourself in such a predicament, it is important to seek outside legal counsel to avoid or limit facing any personal consequences.

One effective way to address the issue and protect yourself is through the False Claims Act (FCA). The FCA empowers individuals like you who have been placed in an unfortunate situation to report fraud and protects you against job retaliation. By coming forward as a whistleblower you can expose fraudulent activities and help bring the responsible parties to justice.

Additionally, the FCA allows whistleblowers to receive a reward of up to 30% of any recovered funds from Medicare fraud cases as an incentive for their courage and cooperation.

What to Do if You Suspect Fraud

If you suspect that fraudulent practices are occurring in your place of employment, it’s crucial to take the appropriate steps to address the issue. Here are some actions you can consider taking:

  1. Get Expert Guidance. Let us know what you’re experiencing by scheduling a confidential and no-obligation meeting. We’ll help determine what kind of fraud may be occurring and any violations we may suspect.
  1. Gather Information & Evidence. Keep a detailed record of any suspicious activities or instances of potential medical billing fraud that you come across. If any of the fraudulent processes are documented somewhere already, obtain a copy to share with your legal team.
  1. File a Claim. A whistleblower must file a complaint under seal, through a law firm detailing the alleged fraud and supporting documentation.

From here, the government will examine your evidence, review your documents, and may also request additional information relating to the alleged fraud.

During this time, we’ll be by your side to make sure you provide whatever information the government requests. We’ll also be there to remind you not to discuss your case with anyone while it’s under seal.

After the government investigates, it will decide whether it wants to bring formal legal action against the accused. If the government does decide to intervene and take over the prosecution, the case will then proceed through the process of litigation or settlement.

You Are Not Alone

Facing the reality of medical billing fraud can be overwhelming, but you don’t have to navigate this challenging situation alone. At DJO Whistleblower Law Firm, we understand the complexities of healthcare fraud cases and the courage it takes to blow the whistle.

Our experienced team is here to support you every step of the way. When you report fraud through our firm, we will work diligently to keep your information confidential, protecting you from any potential retaliation.

Moreover, as a whistleblower, you may be entitled to up to 30% of any funds recovered as a result of your brave action. By coming forward, not only are you safeguarding your professional integrity, but you are also actively contributing to a more transparent and honest healthcare system that benefits everyone.

Remember, reporting medical billing fraud is a noble act that helps ensure the proper allocation of healthcare resources, protects patients, and upholds the integrity of the medical profession. Your commitment to ethical practice and patient care extends beyond the confines of your practice, and with the right support, you can help create a positive impact on the healthcare industry as a whole.

authored by Christopher J. Piacentile
Director of Investigations DJO Whistleblower Law Group

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