There are some general protections to whistleblowers, but the Patient Protection and Affordable Care Act adds specific protections for those in the healthcare industry. It specifically protects workers from retaliation if they report violations. The act defines retaliation as dismissal, fewer hours, less pay, demotion, blacklisting, failure to rehire, denial of overtime opportunities, reassignments that impact career path, and other forms of punishment.
Typical forms of healthcare fraud
There are many forms of fraud, but some common examples include:
- Billing for services not provided
- Using valid information to create a fraudulent claim
- Billing for non-covered services using fraudulently claimed ones that are covered
- Performing unnecessary treatments for the purpose of billing insurance carriers
- Submitting duplicate claims
- Misrepresenting the service provider
- Participating in illegal kickbacks or referrals
- Prescribing unnecessary medications
- Upcoding for more expensive procedures
Not a victimless crime
Healthcare fraud involves tens of billions of dollars annually here in the United States. This is only a slice of the pie — health expenditures represented almost 18% of our nation’s Gross Domestic Product for a total of $3.8 trillion in 2019. It grew 4.6% that year, which is typical.
Providers and taxpayers shoulder medical and healthcare fraud costs in the form of higher healthcare coverage and billing. This, in turn, leads to the average person choosing to get less expensive or comprehensive coverage, leading to undiagnosed health issues or even death.
With this in mind, whistleblowers need to speak up when there is a systematic case of fraud. These brave souls can notify the FBI or the appropriate regulatory agency and provide evidence to identify the criminal activity.
