Healthcare fraud costs the U.S. billions each year, driving up costs for patients and impacting the quality of care. Employees who witness fraud at work play a vital role in preventing this type of abuse. However, healthcare employees are often hesitant to report fraud, fearing retaliation or job loss.
Swartz Swidler, a law firm specializing in whistleblower protections in New Jersey, is dedicated to helping healthcare employees understand their rights and protect themselves while reporting unethical practices. Below, we outline the signs of healthcare fraud, how to document your observations, and the steps to safely report fraud in New Jersey.
What is Health Care Employer Fraud?
Definition and Overview
Healthcare employer fraud includes deceptive or illegal practices conducted by healthcare providers or organizations to gain financial benefit. This type of fraud is damaging to patients, taxpayers, and the healthcare system overall.
Types of Healthcare Fraud in New Jersey
- Billing for Services Not Provided: Charging for procedures, treatments, or tests that weren’t actually administered.
- Upcoding and Unbundling: Billing for a more expensive service than was provided (upcoding) or billing separately for related services that should be billed together (unbundling).
- Kickbacks and Referrals: Offering illegal incentives to other healthcare providers for patient referrals.
- Medicare and Medicaid Fraud: Submitting false claims to government-funded healthcare programs, which is illegal under both state and federal laws.
Types of Healthcare Employer Fraud in New Jersey
Why Health Care Fraud is Harmful to Patients and Employees
Healthcare fraud not only wastes public resources but also puts patients and employees at risk.
- Patient Safety Risks: Fraud often leads to poor quality of care, misdiagnosis, and even harmful treatments, compromising patient safety.
- Financial Burden on the Healthcare System: Fraudulent activities inflate healthcare costs, impacting insurance premiums and patient expenses.
- Workplace Ethical Challenges: Employees may feel pressured to participate in fraud or turn a blind eye to protect their jobs. Knowing their rights can help employees resist unethical practices.
How to Recognize Signs of Health Care Fraud in the Workplace
How to Recognize Signs of Health Care Fraud in the Workplace
Recognizing healthcare fraud can be challenging, as it’s often hidden within billing and administrative processes. Here are some common signs to watch for:
- Suspicious Billing Practices: Repeated inconsistencies in billing or unusually high charges for routine services.
- Unusual Patient Diagnoses: Patterns of inflated diagnoses to justify costly treatments or procedures.
- Incentives for Referrals: Any offers or incentives for referring patients may suggest illegal kickback schemes.
Documenting Suspected Fraud
- Record Observations: Track dates, times, and specific details of any unusual activities or discussions that raise suspicion.
- Collect Documentation (if safe and legal): Keep copies of emails, billing records, or other documents related to the fraudulent activity. Avoid violating company policies or privacy laws while collecting evidence.
Steps for Reporting Healthcare Fraud in New Jersey
Steps for Reporting Health Care Fraud in New Jersey
1. Report Internally (if safe)
- Identify Trusted Channels: Start by reporting to a supervisor or compliance officer within your organization, if possible.
- Know the Whistleblower Policy: Check your workplace’s whistleblower policies to understand internal reporting protections.
2. Report to External Authorities
- State and Federal Reporting Options:
- New Jersey Medicaid Fraud Division: Contact this department to report Medicaid fraud within the state.
- Centers for Medicare & Medicaid Services (CMS): Report Medicare fraud directly to CMS, which investigates federal program fraud.
- Whistleblower Protections: Both New Jersey and federal laws provide protection from retaliation for employees who report healthcare fraud.
3. Consult an Attorney
- Role of Legal Assistance: Consulting an attorney can be critical in healthcare fraud cases, as they can help you understand and protect your rights throughout the process.
- How Swartz Swidler Can Help: With extensive experience in whistleblower and healthcare fraud cases, Swartz Swidler offers guidance to ensure employees are protected and informed about their options.
Protections and Potential Rewards for Whistleblowers
Whistleblower Protections Under New Jersey Law
- New Jersey Conscientious Employee Protection Act (CEPA): This state law protects employees from retaliation if they report healthcare fraud or other unethical practices in the workplace.
Federal Protections
- False Claims Act (FCA): This federal law covers whistleblowers who report fraud against government programs, providing anti-retaliation protections and potential financial incentives for successful cases.
Potential Rewards for Reporting Fraud
- Financial Rewards: Under the FCA, employees who report fraud that leads to recovered funds may receive a percentage of the amount recovered.
- Legal Recourse for Retaliation: Employees who experience retaliation for reporting can pursue reinstatement, back pay, and compensation for emotional distress.
Common Challenges When Reporting Healthcare Employer Fraud
Fear of Retaliation
Employees are often afraid to report fraud due to potential retaliation, such as demotion or termination. However, CEPA and federal laws provide protection against retaliation, helping employees feel secure in reporting misconduct.
Burden of Proof
Reporting fraud requires evidence. Having strong documentation, such as emails, billing records, and witness statements, is crucial to substantiate claims and ensure the case moves forward.
Emotional and Workplace Pressure
The decision to report healthcare fraud can bring ethical and emotional challenges. Swartz Swidler provides support to help whistleblowers feel confident and protected throughout the process.
Why Choose Swartz Swidler for Your Whistleblower Claim
Expertise in Healthcare Fraud Cases
Swartz Swidler has extensive experience handling healthcare fraud cases in New Jersey, giving clients confidence in our expertise.
Dedicated Client Support
Our client-focused approach means each case is handled with personalized support, helping clients navigate the legal process with ease and professionalism.
Proven Advocacy
Swartz Swidler has a strong track record in defending whistleblower rights and achieving positive outcomes for clients, making us a trusted advocate in healthcare fraud cases.
Taking the Next Step: Contact Swartz Swidler Today
If you’re ready to report healthcare fraud in New Jersey, Swartz Swidler is here to help. Contact us today for a confidential consultation, and we’ll help you understand your options and take the steps needed to protect your rights. Don’t let unethical practices go unchecked—reach out to Swartz Swidler for trusted legal guidance.
