Monday, December 9, 2013

How to Get Rich as a Whistleblower

     This is a no-cost, risk-free investment strategy.
     When it pays, which is often, it pays big.  Though simple, it requires patience.  It could take ten years to see a return for your efforts, but it's likely to be less and it doesn't take much energy.  It might be a good retirement plan.
     You must be willing to be a whistleblower.  You'll have to throw aside compunctions about morals, but so what?  The big guys do it all the time--why shouldn't you?  This is about opportunism, which the government has made its modus operandi for a decade or two.  If you help the government, it will pay you royally.
     Since most whistleblower cash-ins are in the healthcare field, it's best to apply for a job in healthcare.  During your interview, pose as someone who knows a lot about billing and coding and can also work on A/R.
     You might consider taking a short course in medical billing, to learn the jargon.  Jargon is very impressive to higher-ups, including those with government posts.  They're likely to make decisions based on whether you seem to know what you're talking about.  And since medical billing and coding is mumbo-jumbo to laypeople, it will be easy for you to look like an expert.
   If you already work in healthcare, you're a step ahead.  Nurses and medical assistants can establish whistleblower "retirement plans" like the one I'm about to describe, but they'll have more credibility if they spend time in a billing department.
     If you need millions of dollars to satisfy your retirement needs, plan to blow the whistle on a hospital or a large-scale multi-specialty group.  If you're more modest, choose a family doctor or a small group.  It's easier to garner trust in a small office, and that allows you to get away with more.
     Soon after starting work, look for "holes" in your employer's billing practices.  A hole could be not enough documentation to support the visit coded, or no order for the service in the chart, or no clear indication of necessity for the service.  This is the kind of accusation you need to blow the whistle, quit your job and collect unemployment.  After that, just wait.  Tell the unemployment officer that you couldn't bear to work for someone so immoral.  Say that you could see your employer was committing fraud--that is, breaking the law--and it really bothered you.  You didn't want to become party to a crime.
     Finding ways to attack and blow up your employer is easy--they're all over the place.  It's not that doctors are committing fraud all the time because, really, they're not.  But the medical coding and billing rulebooks are a jungle loaded with land mines.  It's almost as if they were put there on purpose--for you to get rich!
    One important thing.  You should read the False Claims Act--look up:  31 U.S.C., paragraphs 3729-3733.  It's a statute that dates back to 1863, but in 1986 it was amended to make it easy for the government (and you) to "recover" money and levy stupendous "penalties" for services Medicare has already paid to healthcare providers, .  The statute casts a wide net and uses such opaque language that it can be made to apply to just about any physician who accepts Medicare assignment.  This is partly because the rules that dictate how physicians are supposed to code and bill fill 30,000 pages, are imprecise and self-contradictory, and change a little every month or two.   That's why it's so easy for you to make your fortune.   Don't worry about getting the "right" healthcare job for carrying out your plan.  Any medical facility will do.  Choose one with revenues that match your retirement needs.
     The easiest way to do this is to keep your job for a month or two, then call Medicare, the FBI or a lawyer who accepts "cases" like this, and say your employer is committing fraud.  Use your jargon, and be sure to mention, offhandedly, some of the offenses listed in the False Claims Act.
     Here's are sample scripts:
     Hi, I''m just a billing clerk, and I don't want to get anyone in trouble, but I think the doctor I work for is committing fraud.  Yes, well, it's like he's making us bill for things he didn't do.  And lots of times he orders tests that aren't necessary for the patients.  I think he's "upcoding," and I also think he might be "using false diagnosis codes to obtain coverage for services."  
     Or:  I'd like to report something to the FBI that I don't think is right.  The clinic where I work is "mischarging for goods that weren't provided."  It's also "providing inferior products" to patients.  I don't want to be a whistleblower, but I just don't want to see anyone get hurt.
     Or:  Hello, Sir.  I know the Medicare program is having a lot of financial trouble, and I hear that doctors are committing fraud all over the place, and I think that's terrible.  I want to help, but I'm afraid if I tell on my employer I'll get in trouble.  Still, I have to report this, I really do.  I think my boss is "charging federal programs for devices that are not covered," and "misrepresenting those devices as having FDA approval when they don't."  And he could be "submitting false cost reports."  Could this be a problem, Sir?
     Simple, isn't it?
     You work for a few months, then call Medicare or the FBI and "report" your boss by using some of the language from the False Claims Act.  It's practically foolproof.  The toll-free phone number for "reporting" your suspicions is on the Medicare website, as well as on every patient's monthly Medicare statement.  The government wants to make it easy for you to "help."
     If you're more aggressive, you can set your boss up for trouble..  You can create the very problems that you then report, and your boss will get in trouble, not you.  In fact, you'll get rewarded for "reporting" it.
     For example, get a job with a new doctor who needs to apply for participation in the Medicare or Tricare programs (a simple process).  Pretend to fill out and submit the requisite applications.  In a month or two tell the doctor the applications have been approved.
     "Should I start sending claims to Medicare?" you might ask.  The doctor will say yes, and you'll transmit "false claims" for patients who have Medicare.  A month or two later, call the FBI and inform an official that your employer is committing fraud by billing claims to Medicare without approved provider status.  You'll become the whistleblower and be in line for up to 30% of whatever the government takes back, usually through a settlement.  It could be a lot more than you think:  providers have to pay back three times as much as they were "falsely paid," as well as fines of $5,500 to $11,000 for each "false claim."  Your percentage could be millions of dollars.
     If the doctor already accepts Medicare, you could transmit claims for services the patients didn't get.  Just look them up in the CPT book, and make sure the diagnosis and procedure codes match.  The highest paid are for cardiothoracic surgery and chemotherapy, but loads of smaller codes might earn you more in the long run, because of the accumulation of per-claim fines.   Your false claims will be paid swiftly because computers authorize payment.  You won't be held responsible for the falseness of the claims, but you can make sure your boss is.
     The Seventh Circuit's 2008 decision in United States v. Rogan, 517 F.3d 449 says that if a clinic sends claims to Medicare when it hasn't "met the conditions of payment" it has broken the law.  Not completing an application to Medicare and receiving formal approval, is equivalent to not meeting the conditions of payment.  Even if the physician has provided necessary services to Medicare patients it's a breach of the law for claims to be sent without Medicare status.  Trusting you to have obtained such status was your employer's mistake.   So was trusting you to send accurate claims.  The provider or clinic owner will be held responsible for the breach, not you--but you can collect on the damages.  That will allow you to quit your job.  You may even be treated like a hero for helping to crack down on Medicare fraud.
     In fact, you don't have to understand anything about documentation and billing to be a whistleblower.  You can simply call the FBI or Medicare and say your employer is committing fraud.  The government will pick up the case and do all the legwork, at no cost to you.  Its agents will confiscate and comb through your employer's billing and medical records and are sure to find "problems."  Prosecutors can decide, nowadays, that doctors aren't making good medical decisions and therefore should be arrested and made to pay back the government for services that "weren't necessary."  Prosecutors can argue that a doctor's medical charts aren't complete enough, or that they're too formulaic.  Who argues with the government?
    The doctor will "settle," especially if the government confiscates the money he needs for legal representation--and that means you'll get your payoff sooner.  Everything works in your favor.
     When it's all over, you can do the same thing again.  It's kind of a career, isn't it?    


  1. Are you saying that your employees did all this? The employees that you said in previous blogs you trained yourself that they had little to no medical experience?

    We are all still awaiting for your blog concerning your interpretation of the "incident to" billing you stated would be coming.

    1. The post to which you refer is an ironical look at current whistleblower legislation. It has no relation to my office, my past employees, or anyone I know.

  2. I found this:

  3. Regarding NPP's and Incident to Billing Criteria (Medicare Option #2):

    "There must be direct personal supervision by the physician as an integral part of the physician's personal in-office service. The physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary;"

    Under what exceptions may a physician not be physically present?

  4. It saddens me to know that an ex-employee of your caliber (I believed) (for surely you are one of my past employees, as I recognize your style of expression) would seek any means of fingerpointing, to make me out to be a "criminal," even searching the copious billing and coding guidelines--which differ for Medicare patients in certified rural clinics vs Medicare patients in non-rural clinics, especially with regard to the requirement for on-site physician supervision--in order to brand me guilty of something, anything at all! Like the prosecutor's best assistants, you have scoured the 30,000 pages of Medicare billing guidelines looking for a way to apprehend me. Please refer to Rural Health Clinic rules--another set of rules!--for the stipulations about NPs and PAs, because these providers can and do (and are permitted to) work alone in most of the country's rural clinics. What you illustrate, in fact, is the onus put on physicians to be aware of many sets of ever-changing rules and regulations (different ones for each insurance carrier!) while managing the business aspects of their clinics, staying abreast of medical advances and new pharmaceuticals, caring for patients, teaching staff new skills, and hoping that employees like you will assist in maintaining the uprightness of the facility, not look for ways to attack and undermine it.

  5. In reference to your mention of the ever-changing rules and regulations, most clinics are not one person managed. Usually you have a Medical Director that oversees the care of the patient and then a office manager that oversees the actual operations of the office tasks. The office manager would do compliance checks or hire someone to perform these checks on all claims. Was there compliance checks within your office? Basically, did you hire a certified professional medical billing coder to review and audit charts and claims? If so were these discussed with you? This procedure helps to lower errors in billing practices and makes sure the physician is properly informed of the changes in AMA rules and practices.

  6. Once you obtain Rural Health Clinic status, can you follow the liberal RHC rules yet continue to bill on a fee-for-service basis?

    1. RHC rules are not "liberal." They involve more red tape than Medicare's standard and supernumerary rules, and annual cost reports, and tallying of statistics on physician shortage areas. Hawthorne Medical Center had rural health status, which allowed it to use NPs and PAs with offsite supervision, but the transition to billing for RHCs was supposed to be assumed by the new owner, when the clinic was sold.

  7. There are some pretty dramatic examples of folks that have cashed in on whistleblower lawsuits. That said, was this case premeditated from the start or is it an attempt to recoup some of the losses of a failed business venture?