You have been working for a physician in private practice for 8 months. You start to see a pattern with several of his workers’ compensation cases. Each of these patients seems to have more tests and procedures ordered than others with similar conditions. One day the physician asks you to complete and send a billing claim to the insurance carrier for a procedure that you do not think he performed. What are your responsibilities, and what would you do?

I have been working for a physician who is in a private practice for 8 months. I have started to see a pattern with several of his workers' compensation cases. The patient's seem to have more tests and procedures ordered than others with similar conditions. The physician asks me to complete and send a billing claim to the insurance carriers but its for a procedure that I don't think he has performed.

So what would be my responsibilities, and what should I do?

Explanation:

Workers compensation fraud (or filing false claims) is not only unethical, it is considered a crime.

If you suspect a provider is committing insurance fraud, even if they are your employer, you should report it. If you are a participant and knowingly file claims that you know or suspect are fraudulent, you can be implicated. You are especially at risk if there is evidence that you knew the workers comp claims being submitted were fraudulent. In many situations filling false claims can be punishable with jail time.

Keep good documentation and records with names, dates, and any other specifics. Remember this is also for your own protection.

If the doctor is verbally telling you to bill for charges - I couldn't or do that. When a biller knowingly and willingly participates in insurance fraud - they are guilty also.

Hopefully all the procedures your provider is telling you to bill for are documented - on something like a superbill or his patient encounter notes - evidence that shows the provider performed the procedure(s). In a situation like this it’s important to protect yourself and make sure there’s nothing the doctor can blame you for if he gets accused of fraud - or prosecuted.

Ultimately the doctor is morally and ethically responsible for the procedures he performs - or says are performed. We (the biller) are not in the exam room to know what the doctor did or didn’t do. But as a medical biller I feel I have an ethical obligation to report flagrant and obvious fraud when the temptation may be to look the other way.

I understand the dilemma is that if the biller reports this to the insurance carrier, they put their job in jeopardy. Of course if the doctor really is committing fraud it makes you wonder if you really want to work there - if you really want to work for someone with questionable ethics. They will eventually get caught.

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