Reporting Unethical Practices – Medical Coding and Billing

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Q:  “Could you cover reporting ethical concerns in a future webinar? Attempting to notify the facility of unethical practices could lead to termination and adverse effects on future employment. Should coders keep quiet for the sake of their career?”

A:  To me, there should be no doubts on whether an employee should remain silent when reporting unethical behavior in the workplace. There are no guarantees that the coder/employee, will not be terminated, temporarily suspended or demoted. But regardless of the outcome, let’s just say that the employee is allowed to stay on, he or she still suffer because she’s regarded in a different light and she might suffer the consequences of his or her actions in that way. But honestly, I would never keep quiet for the sake of your career. It is not worth the risk. It’s just unacceptable and not worth compromising your own belief system.

In addition to that, depending on what your role is in the facility or the medical practice, for any reasons, someone else is a whistleblower or something happens, you would be involved in all of that as well, and you don’t want to be part of that. But let’s assume that the unethical behavior had something to do with coding, one of the things that is brought up a lot in the medical billing and the practice management course, and it is addressed in the coding course as well, is the False Claims Act and that has one of the strongest whistleblower protection provisions in the USA. It has many complicated components and requirements, which can harm any person that pursues such a claim without legal counsel. So, it really is involved.

Due to the potential for a significant financial recovery, it is usually possible to retain an attorney for such an action. If you go online and you type in “whistleblower” or is it qui tam? There are so many attorneys listed that will support you in this type of a situation, so it is very involved.

The False Claims Act does allow persons or entities with evidence of fraud against federal programs or contracts to sue the wrongdoer on behalf of the United States Government. If the government wants to get involved, they can, but if they don’t want to get involved, they can decline. The person who is the whistleblower in this case would still be able to move forward with the accusation of fraud or whatever wrongdoings are going on in the facility. Some states also have laws concerning fraud with the state government level, so it’s just not all federal. I also know that there are a lot of carriers, at least in my state that they have hotlines or anything that’s going on that’s unethical as well, so there are hotlines there.

You want to investigate the facility you work at as well to see if there is any type of Compliance Plan in place because there may be provisions in the compliance plan that spell out the repercussions of your actions. If there is a plan in place and you do see a violation, there may be steps that are already written in the protocol that you would follow. But no matter what, never compromise yourself. I have been witness to being involved with a whistleblower situation and when I own my billing company, I was investigated just like the person, the provider that was the unethical person and until I proved myself innocent, I was under investigation by the justice department as well as the Health and Human Services.

So, if you see something going on and you don’t do anything about it, you may end up being implicated as well. For me, I follow an OIG plan and I kept a paper trail like you wouldn’t believe and thank goodness I did because it saved me. And I ended up working for the government as well as for the provider that was in trouble and I’ve gone to court in fraud cases and every provider has ended up in jail, so it’s not worth it. Yes, you don’t want to lose your career, but at the same time if you know something is not right, I would take action and walk away if I had to. But that’s my opinion, that’s really all I could say about that.


Alright. Thank you, Jo-Anne


Can I add one piece of information to that?




I totally am right there alongside with you Jo-Anne, and the fact that if you keep quiet, you got to think about whether or not you’re violating the ethics that you agreed to with the AAPC because you know about it and you kept quiet, you’re just as guilty as the person who is committing the act in their eyes.


And that’s true with the Office of the Inspector General, their whole compliance plan. You are in violation, if you’re aware of the violation, so you’re right. It’s just unethical across the board and it’s not worth it, it just isn’t. One door closes, another one will open, and it’s always held true for me. I just could not compromise myself like that. I’ve terminated some lucrative practices over the years just because I wouldn’t want that path, so you have to do what’s right and that’s the bottom-line.

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