A continuing education class on the use of CPT® codes got an Oregon woman wondering whether her employer used the wrong code, intentionally, to make sure insurance paid for procedures. This Oregon business performed CT scans, mammography and other radiological procedures. CPT® codes (Current Procedural Terminology) are reference numbers for medical procedures established by the American Medical Association. Insurance companies, Medicare and other payers rely on CPT® codes when deciding whether to pay for a procedure and, if so, how much.
After some more research, my client decided that she might be participating in civil fraud and criminal activity if she continued working. If caught, at a minimum, she might lose her professional licenses. At worst, she'd go to jail and be sued. So she quit, and wisely so.
In Oregon, it is against the law to present false bills for health care services or supplies. Participation in it is a felony. Oregon law also defines "racketeering activity" to include false medical billing.
The federal false claims act also makes illegal any false claims submitted for payment to the federal government, including medical bills paid by Medicare. The federal law has a "Qui Tam" provision. That means the whistleblower can earn a reward or bounty for money recovered by or for the government. The whistleblower earns a percentage (15% to 30%), the amount of which depends on whether the government prosecutes the claim or whether the whistleblower and her attorney prosecute the claim. Under the federal false claims act, anyone with knowledge can pursue the claim, not just employees.
Oregon and federal laws protect current employees who blow the whistle on cheating employers. That is, if an employee reports false CPT® coding - or other medical fraud -- to the authorities, the employer may not fire her or otherwise change her working conditions.
My client decided against pursuing a whistleblower claim under the federal false claims act. She believed that the best we could do is win a worthless judgment against a corporation that was about to go out of business. But for those of you working for big enterprises - such as national assisted living facilities or big hospitals -- that are cheating Medicare, keep in mind that you can provide a great service to all of us taxpayers if you decide to become a whistle blowing, Qui Tam, bounty hunter.
Jeff Merrick, Oregon Trial Attorney
Injury & Employment Law
http://www.jeffmerrick.com 503-665-4234
The above is not legal advice. I cannot give you sound advice without knowing more information. It is intended to raise some issues for you to discuss with your own lawyer.
