I was fired for detecting insurance fraud.

[knitpurl]

I am a 3.5-year experienced cardiology PA in a private single-MD practice.  A month ago, I noticed that my MD was submitting a CPT code in his name for every single clinic patient I saw.  He was sometimes putting the bill in the EMR before I finished my note and assessment and plan.  He personally only saw my patients if they were new or complicated, accounting for 10% of my volume.  

 

At the time I saw all of these bills under his name, I was submitting paper superbills (for unrelated reasons).  I thought this was just some misunderstanding where he didn't see me entering my own bills electronically, so he was putting in the billing under his name.  I told my manager that he was double billing- his electronic CPT entry on top of my paper one.  Could she please talk to him and ask him to stop?  I did not want him to get himself in trouble and it seems to be a misunderstanding.  Yes, oh yes she would... No, no no, he cannot do that.  I made sure she had copies of the incident-to billing guidelines for Medicare in case he needed them.  

 

Days passed and I asked for an update.  She said she was still discussing it with him.  Then a week passed, and I asked again.  She had spoken with him and shown him the incident-to guidelines.  He said he was not going to stop billing all of my patients in his name.  He said his personal lawyer advised him that he could do it.  I told her that his personal lawyer is not my lawyer and he is kind of implicating me in fraudulent billing at this point and I don't want to be a part of it.  She told him that if he refused to stop doing it, his PA might then quit.  He told her, "ok."  At this point it had progressed beyond a misunderstanding of billing to having full knowledge that what he is doing is against the rules and refusing to stop.  She said she would speak with him again.

 

We met again.  "Well, there's good news and there's bad news.  The good news is that he is going to stop billing all of your patients in his name.  The bad news is, he wants you to look for a new job."  I was totally stunned.  This was not the outcome I was expecting.  He did not clearly articulate to my manager why I was being asked to move on.  I prepared my resignation letter to hand in at the end of my workday. 

 

Before the day ended, my MD spoke with me privately.  He said his recommendation for me to find a new job was not based on money or billing or my job performance but on several other unrelated things.  He did not want me to storm off the job today in anger.  I could take my time finding my next job, he would provide recommendations, he would accommodate job interviews as needed.  It was a positive discussion and I did not disclose that I was on the edge of quitting before he spoke with me.  

 

The next week was uneventful.  At the end of each of my clinic days, I provided him with a list of the patients I saw that qualified as incident-to that he could bill in his name.  On my last day of that week, he had a vacation scheduled so he was gone for the afternoon.  When I finished seeing my last patient, my manager pulled me into her office and presented me with a letter from the MD.  It said that this was my last working day and to finish all of my documentation by the end of the day.  I would get 2 weeks severance, 4 weeks of unused paid vacation time.  No explanation for why he was suddenly firing me.  The manager did not see it coming.  Perfectly timed for when he was going to the airport so he would not have to talk to me.  The employee termination form required by my state says "reason for termination: wanted to replace PA with MD."  My doctor has not spoken to me, emailed me, or anything else.  That was a week and a half ago.

 

I am currently looking for a job in the same area where this doctor is located.  He is well-known and would certainly talk badly about me if he found out I was telling prospective employers the real reason why I got fired.  My biggest obligation right now is to ensure I secure my next job.  I have a 9 month old baby.

 

Should I report the insurance fraud?  If so, when?  Does anyone have experience in reporting this or reporting an employer for firing them under such circumstances?

 

I appreciate any comments or advice.  I've learned to never underestimate a doctor's ego.....  If he didn't fire me for finding the fraudulent billing, he definitely fired me for going to the manager about what he can and can't do.

 

 

 

[LKPAC]

If you don't report this fraud, then you are an accomplice.  

[mandrew1]

I was involved with a cardiologist who billed level 4's for every medicaid/medicare pt "because they don't pay." he also was doing cardiac catheterizations at the hospital on Mondays while I saw his pt's in the office in another town. He billed for my visits too! How could he be in two places at once. The group was in chaos and very unethical. I filed a Whistle Blower complaint (anonymously) and had an agent , wearing a gun, sitting in front of me in no time. Unfortunately, nothing came of it. I quit.

 

I think that you may have a good law suit however. He clearly fired you because you were putting pressure on him to do the right thing. Even if you're in an "at will" state, it would be quite obvious why he fired you. He probably wouldn't want the exposure either. But, I'm not an attorney and I'm not pretending to provide you legal advice.

 

Having said that, you do run the risk of being "black listed" in your area. Sometimes we have to ask ourselves , "Do I want to be right, or do I want to be happy?"

 

Good luck with the job search. 

[True Anomaly]

Lawyer up.  Seriously.  You might have a whistleblower case, but that of course depends on your state laws

[rev ronin]

I was involved with a cardiologist who billed level 4's for every medicaid/medicare pt "because they don't pay." 

Then he's entirely ignorant of how to bill a level 4 visit properly.  I bill almost everything as a level 4... not because anyone does or doesn't pay, but because under the '95 rules it's pretty trivial to get a level 4 billing: 2 stable chronic illnesses, 1 chronic illness exacerbation, 1 uncertain prognosis, or any prescription drug management: just do the appropriate H&P for level 4, and it's good.  I dunno about you, but in CARDIOLOGY, every single visit should meet level 4 criteria, else it should have been handled by the PCP...

 

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnedwebguide/downloads/95docguidelines.pdf

[CAAdmission]

Get yourself into a whistleblower situation and blow hard. If they get spanked for fraud, you usually are entitled to a substantial reward.

[south]

Classic whistleblower case.  You need to speak to an employment and/or medical insurance fraud attorney familiar with this situation.   I'm guessing this situation is increasingly common, especially as docs get squeezed more and more.

 

You have significant exposure here for two reasons that spring up immediately:  

 

1.  You probably (from what you wrote) don't have much in the way of documentation.  I hope I'm wrong.  The ambush firing is an attempt to get you out of the building permanently before you can print or save anything.  

 

2.  Counterclaim retaliation.  The way you wrote this, if I was in that MD's shoes, I would think about claiming that it was YOU that billed HIS patients but did not see them.  I would threaten you with it at the very least.  The office manager could tell the truth here, but she would be on the street as well.

 

I dunno, it looks to me like this guy's neck is way out there and he's pretty exposed in a few different ways.  No wonder he killed you off like he did.  Depending on how long this has been going on, he is at risk for a lot of things I can't even speculate on.

 

(I'm assuming you live in an "at will employment" state so the firing is a non-starter other than the whistleblower angle). 

 

I'm really tempted to suggest another conversation with him, post your consulting an employment/fraud attorney.  Get a couple of business cards and make sure you open with them.  Or maybe even pay him or her to attend.  That conversation might cover your willingness to withdraw a slam-dunk wb case if he accepts your resignation and you can call it that, and a far more generous severance package for being dropped on your head like that.  Not having to check the "have you ever been fired from a job" box is kind of a thing.  

 

edit:  Probably getting way too excited here, but wondering if a continuation of your salary until you find comparable employment is an option.  This means he has a vested interest in providing a positive reference, etc.  

 

(I don't think it's legal to blackmail him for the fraud complaint - just the wb part).

 

If you stay fired, then burn him down.  I don't see as you have a choice.  He's probably going to get caught and you may be implicated.  

 

Sorry this is happening.  So sad.  But attorney, asap.  Let us know what happens. 

[overthehorizen]

Be certain of one thing. Doctors will lie to advance themselves. Anyone who benefits from a relationship with the doctor will easily be coerced by the Doctor to lie on the doctor's behalf. We must remember that we are "aligned" in a "team" with a group of animals whose goal is to profit from us while harming us. People object when I use the word "slavery" here but there are many distinct similarities. 

[sas5814]

I am a 3.5-year experienced cardiology PA in a private single-MD practice.  A month ago, I noticed that my MD was submitting a CPT code in his name for every single clinic patient I saw.  He was sometimes putting the bill in the EMR before I finished my note and assessment and plan.  He personally only saw my patients if they were new or complicated, accounting for 10% of my volume.  

 

At the time I saw all of these bills under his name, I was submitting paper superbills (for unrelated reasons).  I thought this was just some misunderstanding where he didn't see me entering my own bills electronically, so he was putting in the billing under his name.  I told my manager that he was double billing- his electronic CPT entry on top of my paper one.  Could she please talk to him and ask him to stop?  I did not want him to get himself in trouble and it seems to be a misunderstanding.  Yes, oh yes she would... No, no no, he cannot do that.  I made sure she had copies of the incident-to billing guidelines for Medicare in case he needed them.  

 

Days passed and I asked for an update.  She said she was still discussing it with him.  Then a week passed, and I asked again.  She had spoken with him and shown him the incident-to guidelines.  He said he was not going to stop billing all of my patients in his name.  He said his personal lawyer advised him that he could do it.  I told her that his personal lawyer is not my lawyer and he is kind of implicating me in fraudulent billing at this point and I don't want to be a part of it.  She told him that if he refused to stop doing it, his PA might then quit.  He told her, "ok."  At this point it had progressed beyond a misunderstanding of billing to having full knowledge that what he is doing is against the rules and refusing to stop.  She said she would speak with him again.

 

We met again.  "Well, there's good news and there's bad news.  The good news is that he is going to stop billing all of your patients in his name.  The bad news is, he wants you to look for a new job."  I was totally stunned.  This was not the outcome I was expecting.  He did not clearly articulate to my manager why I was being asked to move on.  I prepared my resignation letter to hand in at the end of my workday. 

 

Before the day ended, my MD spoke with me privately.  He said his recommendation for me to find a new job was not based on money or billing or my job performance but on several other unrelated things.  He did not want me to storm off the job today in anger.  I could take my time finding my next job, he would provide recommendations, he would accommodate job interviews as needed.  It was a positive discussion and I did not disclose that I was on the edge of quitting before he spoke with me.  

 

The next week was uneventful.  At the end of each of my clinic days, I provided him with a list of the patients I saw that qualified as incident-to that he could bill in his name.  On my last day of that week, he had a vacation scheduled so he was gone for the afternoon.  When I finished seeing my last patient, my manager pulled me into her office and presented me with a letter from the MD.  It said that this was my last working day and to finish all of my documentation by the end of the day.  I would get 2 weeks severance, 4 weeks of unused paid vacation time.  No explanation for why he was suddenly firing me.  The manager did not see it coming.  Perfectly timed for when he was going to the airport so he would not have to talk to me.  The employee termination form required by my state says "reason for termination: wanted to replace PA with MD."  My doctor has not spoken to me, emailed me, or anything else.  That was a week and a half ago.

 

I am currently looking for a job in the same area where this doctor is located.  He is well-known and would certainly talk badly about me if he found out I was telling prospective employers the real reason why I got fired.  My biggest obligation right now is to ensure I secure my next job.  I have a 9 month old baby.

 

Should I report the insurance fraud?  If so, when?  Does anyone have experience in reporting this or reporting an employer for firing them under such circumstances?

 

I appreciate any comments or advice.  I've learned to never underestimate a doctor's ego.....  If he didn't fire me for finding the fraudulent billing, he definitely fired me for going to the manager about what he can and can't do.

Yes you should report it. First of all if you don't then you are complicit in what is and will continue to be insurance fraud. Second you may want to consult an attorney. You need to protect yourself and, if so inclined, take legal action against the physician. You were fired for trying to stop fraud. There is also a question of whether you should report him to the medical board. His actions were intentional and criminal. The ethical implications should be obvious to the medical board. What you should NOT do is nothing. Even if you don't take a direct affirmative action you need to be prepared for additional fallout. If this physician is that dishonest he might very well lie or manipulate the situation to move some blame to you.

[BruceBanner]

At the very least I would consult an insurance fraud attorney, before you report anything. Might be several hundred bucks but money wisely spent if you ask me. Nothing may ever come of his fraudulent billing but if it does you are absolutely implicated. And chances are he would throw you under the bus. You were definitely fired for sticking your nose where he didnt want it.

[KMD16]

My advise. Move on. Learn your lesson.

 

Your next job. Report any medical fraud. While you keep your mouth shut. Then, immediately get out & find another job.

 

You'll not win the fight. So, don't even think of it.

 

Focus on your family & getting another job. You have a young family to feed. Be honest on your next job interview.

 

If you live in a small town, you better brace for damage control. You indicated that your SP is well known in town. This folks are wicked. Believe me, he care less. You were just another body. Just my 2c!

 

Good luck.

[kargiver]

If he is fraudulently billing CMS and you were billing along with him, you are complacent and will be in as much trouble when the next person finds it and actually blows the whistle.  Talk with an attorney, call CMS and report the fraud.  You are entitled to 10% of any fraudulent charges CMS takes back, and you are given immunity from prosecution as the whistleblower.  CMS lives for this - and if I am reading the politics right, you may very well need this windfall unless you plan on leaving the area. 

G

[MedicinePower]

Definitely inform your malpractice insurance company and you should probably make that notification through your lawyer.

[ventana]

Get yourself into a whistleblower situation and blow hard. If they get spanked for fraud, you usually are entitled to a substantial reward.

wow RUN (not walk) to an attorney for federal whistle blower case

 

yes this will put a black mark on you, but in comparison to getting fired it is much less.......

 

 

lawyer up and fight like heck!! 

[DizzyJ]

I worked in a similar situation.  I contacted two attorneys and neither would take my case because there wasn't enough money for them.  Also filed complaint with CMS and had a call, but no follow up.  Seemed like nobody cared unless it was millions.  

[sas5814]

I worked in a similar situation.  I contacted two attorneys and neither would take my case because there wasn't enough money for them.  Also filed complaint with CMS and had a call, but no follow up.  Seemed like nobody cared unless it was millions.  

Common refrain. The agencies have limited resources so they don't chase after small time violators. I turned in a guy in disability who was running his own trucking company (the small kind that contracts with individuals to move things from point A to point B) and doing all the driving himself. He kept it off the books by using his wife's name on everything. Never even heard back and he is still at it.

[DizzyJ]

The process needs improvement.  It shouldn't matter how much the money is.  All these small amounts combined probably add up to a large chunk.  This office I worked in was a nightmare.  Husband physician/wife office manager situation.  Never ever again.  Aside from fraud, they had numerous employment violations and OSHA.  When the phlebo had a needle stick there was no policy/procedure in place for what she should do.  They never drew source blood for testing and just a mess.  The phlebo came to me asking advice about PEP and so I asked the "office manager" about the procedures and labs.  She had no clue what I was even talking about.  So, I reported them to OSHA.  OSHA came in and handed them a list of citations and several thousand in fines.  My boss then came to me and asked if I filed the complaint.  After stating yes, he said "we should terminate our relationship".  That was then followed by me filing a whistleblower discrimination report and that was followed by my boss giving me a letter that I am not terminated, I may stay, but if I choose leave that is my decision. 

[TWR]

you should notify as many agencies as possible.  Even if nothing is done, down the road if it is caught or if they continue and get caught, you did everything you could do.  Keep a paper trail and put it in your safe.  Sometimes things have a way of coming back years later.

[sillycibin]

Was your physician in the same building as you?  My understanding is that the patient should be billed under the physician's number and you get 100% reimbursement and no he doesn't have to see the patient in follow up appointments, only the initial encounter.  

[DizzyJ]

16 hours ago, sillycibin said:

Was your physician in the same building as you?  My understanding is that the patient should be billed under the physician's number and you get 100% reimbursement and no he doesn't have to see the patient in follow up appointments, only the initial encounter.  

This isn't exactly true.  In some instances incident-too billing is completely appropriate and legal, but not for every patient. 

[FSUnoles]

yea i agree with others to report it but dont except anything to happen

at least you personally cover yourself 

my question is this person better off joining a larger corporation type practice or hospital system. would that offer any buffering from experiencing this again?

[Houstonian]

A one-physician office is more prone to billing fraud than a larger practice with checks and balances and possibly a compliance officer. But larger organizations can also commit organized fraud.  

An employee owes allegiance to her employer.  If one cannot give that allegiance due to flagrant unethical conduct, then resigning (refusing to accept their money) is the right and proper thing to do.  

Seek legal counsel before taking any action, and be sure of the facts of the case and the guidelines for incident to billing.  

 

[Marinejiujitsu]

This is what I understand as well.

Sent from my SAMSUNG-SM-G935A using Tapatalk

[Cideous]

On 7/10/2017 at 5:46 PM, Houstonian said:

A one-physician office is more prone to billing fraud than a larger practice with checks and balances and possibly a compliance officer. But larger organizations can also commit organized fraud.  

An employee owes allegiance to her employer.  If one cannot give that allegiance due to flagrant unethical conduct, then resigning (refusing to accept their money) is the right and proper thing to do.  

Seek legal counsel before taking any action, and be sure of the facts of the case and the guidelines for incident to billing.  

 

http://www.phoenixnewtimes.com/news/nextcare-arizona-based-urgent-care-center-company-to-pay-10-million-to-feds-for-filing-false-claims-6649421