Healthcare billing can be complex, and errors happen for many reasons – a coding mix-up, missing paperwork or confusion about a billing rule. An honest mistake is not necessarily fraud. However, if someone knowingly submits a false claim to a government healthcare program, the False Claims Act (FCA) may apply.
Discovering potential billing fraud can feel stressful, especially when it involves a colleague, supervisor or employer. Understanding common warning signs and your legal protections can help you consider your options moving forward.
What are possible warning signs?
Not every billing error violates the FCA. The law may apply when someone knowingly submits, or causes someone else to submit, a false claim for government payment. Under the FCA, “knowingly” includes actual knowledge, deliberate ignorance and reckless disregard. Possible warning signs include:
- Billing Medicare or Medicaid for services that were never provided
- Knowingly using inaccurate codes to obtain higher payments
- Billing for services that medical records do not support
- Continuing a questionable billing practice after staff raise concerns
- Falsifying records or other documents used to support claims
One mistake does not necessarily mean fraud. The facts matter, including what happened, how often it occurred, who knew about it and how the issue was handled.
What should you do?
If you believe an employer or provider may be submitting false claims, preserve information you are legally allowed to access and consider speaking with a lawyer before taking action.
Write down what you personally observed, including dates, billing practices, instructions and concerns you raised. Save emails, documents and other records you are authorized to keep. Do not alter records, access files you are not authorized to see or improperly take confidential information.
Your employer may also have an internal reporting process. In some cases, that may be an appropriate option. If you may want to pursue a whistleblower claim, consider getting legal advice before making a report.
Are whistleblowers protected?
The FCA provides protection against certain forms of retaliation for legally protected activity related to suspected fraud. Depending on the circumstances, retaliation can include firing, demotion or other adverse employment actions.
If you believe your employer is punishing you for protected whistleblower activity, document what happened and seek legal advice promptly.
Why get legal help early?
You may not know whether a billing problem is an honest mistake, a compliance issue or potential FCA fraud. A whistleblower lawyer can review the facts, explain your options and help you understand how to preserve and report information appropriately.