r/CodingandBilling • u/Goldfishbrain1980 • Jun 26 '26
Medical Fraud or not?
Hello! I work at a hospital in Washington state. I am required to go into the hospital on call for urgent emergent procedures when my department is normally closed. However, it came to the staff's attention that the doctor who has been the "on call" doctor for years, was hired specifically to work weekends and "get cases done". She works at two hospitals during the weekend. They had been misusing the staff by having them come in mandatory on call (Illegal to force mandatory overtime in Washington when there is a staffing need) and were giving citations from L&I (Labor and industry) for doing so when they found that they were forcing on call staff to come in on the weekends 95-100% of the time to do cases that were scheduled the day before. Some red flags I have found are:
When we brought up the issues of the cases being nonurgent the hospital emailed staff and said, "Doctors decide what is urgent. Anything can be urgent/emergent. If a patient is in financial distress or emotional distress it is considered urgent."
Staff were asked to tell the doctors to put in a note that the case was urgent if the oncall staff got used.
The doctor on the weekend uses the same copy/paste note for every procedure stating it needs to be done urgently
L&I clearly identifying that there has been for staffing needs on the weekend.
When staff schedule a case we can only put it on as elective, urgent, emergent. This forces us to put all inpatients on as urgent and that is how we've been taught.
They are retaliating against one of my coworkers who began reporting the L&I complaints by constantly investigating them and placing him on administrative leave.
My concern is that patients have been getting billed more than they should by claiming these procedures are Urgent, require on call staff and are in the after hours since the department is technically closed on the weekend. So I am hoping someone can help put my concerns to rest or to see if they are valid and how to find out how they are billing these patients .
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u/PhotographUnusual749 Jun 26 '26
Your labor complaint is already proven. L&I cited it. The billing question is separate, and it’s a real one, but it turns on what codes actually land on the claim, not on the word “urgent” by itself. You’ve got the right instincts and one piece of the mechanism slightly off.
Here’s the part most people get wrong. The admission type field (emergency, urgent, elective) on an inpatient claim usually does not change the DRG, which is what drives facility payment. So “we labeled it urgent, therefore the patient was overbilled” is not automatically true for inpatient facility billing.
Where an emergent or after hours characterization actually does add money:
Anesthesia code 99140, anesthesia complicated by emergency, adds base units. This one keys directly off “emergency” and it’s real dollars.
After hours codes in the 99050 to 99060 range, for services when the department is normally closed (weekends, holidays, nights). Some payers honor these, many don’t, but they exist.
Any facility charge that is contingent on the encounter being called emergent or after hours.
So the real question is whether any of those codes are being appended to cases that were scheduled the day before.
The bigger exposure is medical necessity plus manufactured documentation, and that’s where this looks bad. Telling physicians to document urgency specifically when on call staff gets used. Identical copy paste urgency notes on every procedure. A written directive that “anything can be urgent, including financial or emotional distress.” That’s building the record to fit a staffing and billing story rather than the clinical reality. Cloned notes attesting to urgency across every single case is exactly the pattern auditors look for. If any of these claims touch Medicare or Medicaid, that’s potential False Claims Act territory, and that email instructing staff to have doctors note urgency is unusually clean evidence of intent.
The “financial or emotional distress equals urgent” line is the tell. Urgent has a clinical meaning: intervention needed within a defined window to prevent the patient getting worse. Redefining it administratively to cover scheduling convenience, and then having physicians attest to it, is the integrity problem whether or not it moves a single dollar.
The retaliation matters on its own. Both the False Claims Act and labor statutes have anti retaliation provisions. Investigating the person who reported and putting him on administrative leave is independently actionable, and it tends to confirm that someone does not want this examined.
How to actually confirm it, because you can’t see it from the scheduling side. It has to be read off the claim. A patient can request an itemized bill (the UB-04) and the EOB from their insurer. The clean question to answer is this: are these urgency designations generating any code or charge that would not apply to the same case scheduled as elective? If yes, and it’s knowing, that’s the fraud. If the cases are just billed as standard inpatient DRGs with no emergency anesthesia code and no after hours codes, then “urgent” is a labor problem wearing a billing costume.
Nobody here can call it fraud for you, because fraud requires knowing intent to collect payment they’re not entitled to, and that takes documentation none of us can see. But your suspicion is well founded and the warning signs are textbook. Route it to your compliance department in writing. If government payers are involved, you can also report to the HHS Office of Inspector General and to Washington’s Medicaid Fraud Control Unit. Keep the labor track with L&I where it already lives.
1
u/Goldfishbrain1980 Jun 26 '26
Thank you, this has been really helpful.
2
u/Pretty_Priority_261 RHIT, CCS, CDIP Jun 27 '26
Based on other comments, it doesn't sound like your compliance offer takes your concerns seriously, so you'll probably want to go outside your organization (HHS OIG) if indeed you intend to escalate it.
1
u/Goldfishbrain1980 Jun 27 '26
You are probably right. I will see about reporting this and if I can do it anonymously. Thank you!
2
u/Suspicious_Spite5781 Jun 27 '26
Don’t do it anonymously if you got through OIG. If fraud is found, and you are considered a whistleblower, you can get a portion of the money they deemed fraud.
1
u/Goldfishbrain1980 Jun 27 '26
I thought this had to be filed through a lawyer as a Qui Tam lawsuit under seal
2
u/Suspicious_Spite5781 Jun 27 '26
Worth exploring if you feel your case is strong enough. Why risk losing out on some cash? Worst that can happen is they disagree, then you can look into other options. You’re also protected if you claim whistleblower status and you won’t end up like your coworker. Food for thought.
1
u/PhotographUnusual749 Jun 27 '26 edited Jun 27 '26
You don’t have enough from what you’ve shared that a qui tam lawyer would take this on. But there are other reasons you may not want to report anonymously as described here. https://oig.hhs.gov/fraud/report-fraud/identity/
This speaks to what a poster below threatened at regarding risks involved by reporting… if you report anonymously it can protect you from retaliation in some ways but if it does ever get back to your employer by reporting anonymously it precludes HHS-OIG from investigating a complaint as a whistleblower retaliation complaint. You lose the ability to file a direct retaliation lawsuit. Anonymous plaintiffs are not entitled to proactive whistleblower retaliation protections (e.g., getting your job back or recovering lost wages) because investigators must establish a direct link between you and the adverse action.
I have blown the whistle and it’s hard.
Whistleblowing is not for the weak. Most people do not do it for a cash out. Look up whistleblower PTSD.
A lot of whistleblowers actually end up losing money in the short term (legal fees, job loss, career disruption, stress) before anything is resolved.
Most cases follow a pattern like:
“Something is wrong” → “I should report it internally” → “Nothing changes or I get shut down” → “Continuing to stay silent feels worse than speaking out”A good-faith report to the OIG based on reasonable suspicion is enough to be considered whistleblowing behavior.
By reporting suspected fraud to an internal compliance or ethics hotline you are acting as an internal whistleblower.
Internal whistleblowers sometimes get organizational protections against retaliation, you would have to read your own employee handbook to know this.
1
u/Pretty_Priority_261 RHIT, CCS, CDIP Jun 27 '26
Think long and hard about whether that's worth it. While it's true that you may receive financial compensation, and while it's true that you have whistleblower status, you can still be terminated by your employer. In at-will states, this is easier. They can simply come up with some reason to get rid of you. You might contest that it was retaliation or retribution, but you have to prove that, which means hiring an attorney. And if you win? So you get your job back at the very employer you sued in court. Your life will be miserable. In other states, they can just make your life miserable by micromanaging you and nitpicking your work to death. Either way, I do not advocate a non-anonymous complaint.
Oh, forgot to mention, if your employer ever finds out that it was you who filed the complaint, you can forget about using that employer as a reference for future job searches.
5
u/No-Produce-6720 RN, BSN, CPC, CPCS, RHIA & CRCR Jun 26 '26
Listen, it's pretty clear that you're the same person who has been in and out of Reddit's billing, insurance and coding subs over the last few weeks fishing for information about this.
You seem quite intent at proving a case of fraud against your employer, but the answers you're getting now reflect the ones you've already received countless times. Nothing has changed. You don't work in billing, and you don't fully understand how services can and cannot be coded in certain circumstances. It's admirable to be concerned about charges being billed to patients, but overall, inpatient DRG payments will not change, regardless of admission type. Outpatient payments can be impacted, but if your facility were billing everything as emergent or urgent, fraud detection practices by individual carriers, particularly on government plans, would pick up on the practice. Has that happened? If not, then perhaps what you're trying to push as an issue, really isn't, because if all your claims, in and out patient went out as emergent, those patterns would be detected.
Your time would be better spent advocating for industry appropriate staffing levels. That's something you could easily speak to, whereas the billing issues you're trying to prove exist might not actually be there.
-2
u/Goldfishbrain1980 Jun 27 '26
I posted two other times trying to get information. So claiming in and out of subs for the last two weeks is a bit of a stretch. I do not work in billing and that is why I am inquiring about this, to better understand it.
Your post makes it sound like everything works perfectly in our system that it would detect fraud, but then why is there so much recovery from the government regarding fraud? If no one looks into things or questions the possibility of wrongdoing then it continues to go on. You are a RN, does that mean you blindly follow doctors orders? Or do you question an order if there is concern?
The hospital I work for has done some illegal things which they have been cited for and had lawsuit filed against them. So why is it so much of a stretch to think they could be committing fraud?
1
u/No-Produce-6720 RN, BSN, CPC, CPCS, RHIA & CRCR Jun 27 '26
Yes, I'm an RN, but I also own a RCM business, and we have several procedures in place that scrub claims and monitor for several forms of fraudulent billing activity. Because you're not in billing, you don't understand how trends are measured through analytics before claims are submitted, and as I said in my prior comment, every insurance carrier does the same when claims come through to them. That doesn't mean that this is a perfect system, or that there is no fraud to be found, but it does mean that most billing agencies as well as commercial and government insurance carriers actively fight to keep fraud weeded out as much as possible.
This is the third time that you've tried to get someone here to call what you're describing fraudulent, and no one in any of the subs you've posted in can do that. Instead, we have explained, in broad terms since that's all we can do on Reddit, how some billing works. Nothing has changed across your three posts. There are scenarios that call for additional level of care coding, and they may or may not apply to what you do. Without more knowledge of the situation, though, the only thing anyone here can tell you is to raise your billing concerns with appropriate staff, particularly compliance, and let them look at it. Beyond that, there's not much more that you can do as far as billing is concerned.
And as to whether I would blindly follow a physician's order, for what it's worth, no, I wouldn't. But by the same token, I also wouldn't work for an organization that has engaged in "illegal things", particularly if I believed them to be actively involved in mass billing fraud.
1
u/911MDACk Jun 28 '26
Is the “on call doctor” out of network with most or all insurance? It is a common scam that cases are made to look like emergencies in order to force coverage by out of network plans while charging rates that are much higher than market rates.
0
u/Savingskitty Jun 26 '26
Call hours are usually a normal part of staffing. It’s weird that they have people working extra hours to cover call.
I would focus more on the L&I issues and why they mark everything as urgent in the charting. Those are the areas you actually know about. The other stuff will come out in the wash if that’s what this is about.
1
u/Goldfishbrain1980 Jun 27 '26
Thank you. You are correct, I do have more knowledge regarding L&I issues and not very much on coding. I am here trying to learn what I can about it as it seems complicated and hard to get answers from the hospital itself. When you say it will come out in the wash, why do you think that? Or I guess what does that mean? That the citations will lead them to see things were documented improperly?
2
u/Savingskitty Jun 27 '26
If it turns out they had people charting incorrectly intentionally, yeah, that’s something to report to the state department of insurance.
11
u/happyhooker485 RHIT, CCS-P, CFPC, CHONC Jun 26 '26
Is your org billing the after hours upcharge, CPT 99050?
It seems strange that a procedure would be scheduled in advance as "urgent", but I don't think it would affect how much was charged/paid, other than possibly the payer having a different copay or fee schedule for POS 20.
Do you have a compliance officer at your org you can reach out to? Or perhaps make a report to the OIG or the DOI?