A question for other doctors only.?

Ultimately, the physician is responsible, even if someone else is doing the billing on her behalf.

I'm not sure what would happen if she reported it, but I imagine (and would hope) that she would not be sanctioned for being used to commit fraud. She is a victim as well.

If I was in your shoes, I would discuss this with the physician, and see if the two of you together can report the fraud as the victims. The problem is that the physician may still be fined, sanctioned or even jailed because of it. The people who prosecute Medicare fraud, from what I've heard, are merciless. She should find a lawyer who specializes in Medicare defense before doing ANYTHING.

And if you try to get a straight answer from anyone at Medicare, you won't. I had a different situation that I wanted clarification on (Stark Law issues) and the answer was "Do what you think is right and if we decide there's a problem, we will prosecute you". I ended up not taking the job where this was a problem out of fear.

The implications of Medicare fraud are immense. Fines of up to (I think) $5000 PER OCCURRENCE, and they will sample a practice's files, and extrapolate the fines to all of the doctor's claims based on the sample. Fines can end up in the $millions.

If you find that the doctor IS in on it, then she needs to be reported. If her reputation and livelihood are at stake due to someone else's crime, then she needs to aggressively pursue having that person held responsible.

Good luck, and update us!

finalx, you could contact medicare directly for a review, but CYA.

who did the billing? the accountant as proxy?

the physician in question would have to sign off it, so direct contact would not be advised.

If she discovered the errors, someone still has to explain the errors. If the doc has an accountant doing the deed, he should probably have another accountant doing billing oversight on the billing firm.

I know of a hospital that bills at $70 when staff looks at the SPO2 monitor because the patient accidentally pulls the monitor off the finger (or a nurse).. (Billed as Cardio/Pulmonary staff)

when it isn't CP staff.

(And seemingly has avoided audits on it)

I've worked in accounting and worked IT in several health related fields, have a lot of contacts in the field. In terms of ethical billing practices there are a lot of people who play it for all it's worth.

Personally I have reported suspected fraud, it infuriates me, and even if the doc is not involved in the billing he should know what his billing people are doing to insure he isn't ripping off patients or being ripped off himself. HE / She is ultimately liable and could deal with a stiff penalty for it.