Posted by: Robert Markette
December 13, 2005

A topic that comes up occasionally with clients is what do I do when I discover an employee has been submitting false clinical documentation.  Many providers have had the panic inducing experience of learning that they have been submitting claims for home health visits that did not happen.  When this occurs, providers have many reflexive reactions.  The most common employer response is to immediately fire the offending employee.  Although ultimately, the employee may need to be fired, you should first consult your corporate compliance plan. 

When you discover an employee has been submitting false claims, the first thing you should do is pull your corporate compliance plan down off of the shelf and read it.  The reason you have a corporate compliance plan is to guide you in these situations.  (If for some unexplained reason you do not have a corporate compliance plan, you should put one together immediately.) 

You should follow the plan as written.  In most instances, the plan will call for you to investigate the situation.  If your plan does not detail the scope or manner of the investigation, you should start by talking with the employee who committed the fraud.  (Yes, before you fire them.)  Often, when confronted, the guilty employee will “come clean” and explain what they have done.  This can be a tremendous help to your investigation.  Of course, you will want to look at every claim and all documentation submitted by the offending employee. 

After you complete your investigation, you corporate compliance plan will likely require you to report the fraud.  Because of your thorough investigtion, you will have determined the amount that will need to be repaid and be prepared to properly explain the situation to the authorities.  Of course, this means you will need to contact the appropriate authorities. In most states that will require you to report to the Attorney General Medicaid Fraud Unit and/or the entity that processed your claims.  

Of course, as the provider, you will need to repay the inappropriately paid claims.  The employee will very likely be prosecuted and then excluded from future participation in both Medicaid and Medicare.

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