Make no mistake—your employees are being encouraged by CMS to report any suspected Medicare fraud. Whistleblower complaints.
CMS offers an incentive to complainants of between 15% to 30% of any money they collect based on the data reported. So, depending on the extent of the violation, this can easily add up to a significant financial incentive.
It’s also important to know that 98% of False Claim Act cases were generated by whistleblowers. In many cases these are loyal employees who have tried to report their findings to management and were ignored. Accordingly, it is critical that you quickly respond to employee concerns regarding billing compliance. The goal is to intercept, defuse and resolve these Medicare complaints before they ever see the light of day.
Triggers for Medicare Whistleblower Complaints
CMS regulations are complicated and confusing. So, they are easy to get wrong. Whether you mean to violate the regulation or not, it really doesn’t matter. If Medicare identifies fraud at your practice, regardless of the reason, they will take action.
The stakes are too high when it comes to CMS fraud. You just can’t afford to be complacent. There are numerous types of fraud that your practice can be found guilty of. Some of the most common types have to do with submitting claims and being reimbursed by Medicare, such as:
- Unperformed services or procedures
- Services provided to ineligible patients
- Unnecessary services or procedures
- Billing for excluded providers services
- A higher level of service than was provided
- Bundled services individually (unbundling) to receive higher reimbursements
Other common CMS violations outside of billing include:
- Kickback: If your practice offers incentive to encourage patients to come to their office. It also includes offering incentives to other providers for referring patients to your office.
- Medical Records: Access, electronic records, charging for record requests
- HIPAA – Patient information privacy and security
- Non-Physician Practitioner Supervision
Whether it’s an honest mistake or someone at your practice is intentionally doing something illegitimate, you’ll save your practice a heap of trouble if you can get to the bottom of these issues internally. You can only do that if your employees express their concerns to you first.
Identify Potential Medicare Whistleblowers
Ideally, you need to reach the whistleblower before they make a report to an outside source. Unfortunately, once they’ve made a compliant, many whistleblowers are super stealth and quiet about their grievances, mostly due to fear of retaliation. While it isn’t always easy to identify the whistleblower before they file a complaint, there are some employee behaviors that should raise a red flag about a potential whistleblower, including:
- Bringing grievances to managers, only to have them go unnoticed
- Sharing openly with at least one or two employees suspicion that fraud is taking place
- Acting disgruntled or rude internally
Avoiding Whistleblower Complaints
If you want to avoid Medicare whistleblower complaints, you need to provide a safe way for your employees to express concerns internally. You can do this by creating an internal whistleblower program. Here are some tips to get started:
- Designate employees outside a normal chain of command to receive and investigate employee complaints
- Provide a way for employees to remain anonymous when filing complaints
- Take all employee fraud complaints seriously and investigate each one thoroughly and fairly
- Guarantee employees that they can speak up without fear of retaliation
- Have a zero-tolerance policy for Medicare fraud by requiring employees report any abuse to you
- Implement a strong code of conduct and anti-Medicare fraud policy that you reinforce in your whistleblower program
Stop Whistleblower Retaliation
One of the biggest reasons whistleblowers keep quiet after they’ve filed a complaint is fear of retaliation. For this reason, it’s critical that you reiterate in your internal whistleblower program your commitment to protecting employees from retaliation.
Another danger is having to discipline or terminate a whistleblower. Remember you may not ever know who they are. Accordingly, it is essential that you keep meticulous documentation if you must implement any of these actions at your practice because any of these can be interpreted as retaliation:
- Termination
- Demotion
- Forced relocation
- Pay deductions
- Social ostracism
- Negative performance reviews
- Micromanaging
- Criticism
Bottom line: If you aren’t proactively engaged in resolving your employee concerns and complaints, it’s only a matter of time before a whistleblower will emerge.
There are several actions you can take to avoid ending up in a whistleblower-generated nightmare. This is where employment law expert, Kelly Holden, JD, comes in. During her upcoming online training on Tuesday, May 11, at 1 pm ET, Kelly will walk you through exactly how you can implement an effective employee complaint process and STOP whistleblowers in their tracks. Don’t wait. Sign up for this online training today.
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