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Is it illegal for me to report suspected Medi - Cal fraud , if it's my own patient ?

Monterey Park, CA |

Some of our babies in our intensive care are born to affluent tourists who come to give birth to US born child . But when baby is ill & comes to our NICU , many parents leave country with baby ( after treatment ) without paying the hospital & / or doctors , or they apply & receive Medi - Cal insurance ( for the very poor ) . Some already enter hospital with approved Medi - Cal . Also , what about the maternity homes or OB doctors that recruit these moms ? I suspect the maternity homes are not licensed and not reporting the income since everything is paid in cash , per the parents . Is it considered illegal for me to report them since I am a registered nurse and employee of the hospital ? Or is it unethical ? If legal , what would be proper way ( e . g . making copies of records to report , etc ) . How do I protect myself ?

Attorney Answers 3

  1. Best answer

    Like any other person, you have the right to report any well-grounded suspicion of actual illegality to the appropriate authorities. Take care that you are reporting only what you know first-hand, and not passing along deductions or assumptions based on your professional position.

    That said, let's be plain about the other side of the issue:
    You do not have the right to covertly reproduce, remove from your workplace, or disclose any documents that are the property of your employer. Be alert to the fact that the subject matter in which you are wading is complex and technical with many fine points, exceptions, and conditions. Don't expect to do this with no consequences if it turns out you are wrong. Be right or don't do it.

    It bears cautioning you in these specifics: don't get up in the cause or drama of your intentions. If you act improperly or unlawfully, your noble purposes will be scant protection. Try hard to separate you your personal views on any social/political issues from your professional responsibilities. Your professional licensing agency requires that of you and will hold you accountable for any breaches or errors. Don't rely on your own ideas or definitions of "whistle-blowers." Lay-persons definitions of this term are almost always wrong, badly so, with horrible consequences.

    The path you propose to take is legally very narrow and fraught with legal and administrative perils, and even an informed and well-advised person is likely to make missteps that can result in the lawful termination of employment or revocation of State license and can even cause criminal prosecution and civil liability. You would be smart to talk with an employment attorney before you set off in this direction. Remember, you cannot recall words. So, as the carpenters say, measure (think) twice, cut/act once.

    The sound course here is to consult with an attorney before acting.

    My responses to questions on Avvo are never intended as legal advice and must not be relied upon as legal advice. I give legal advice only in the course of an attorney-client relationship. Exchange of information through Avvo's Questions forum does not establish an attorney-client relationship with me. That relationship is established only by individual consultation and execution of a written agreement for legal services.

  2. As a health care provider, when you suspect fraud, you have to look at it from the perspective of what if it is fraud. In many other sectors, the intent required to be guilty of a crime is knowledge, but in health care, particularly when dealing with state or federal insurers, the test is what did you know and what should you have known.

    Thus, if a patient acts in a way that makes you suspect fraud, you almost automatically have an obligation to report. But there are steps in between. Do you have a Compliance Officer? You can report to the Compliance Officer, Do you have a hotline, you can report to the hotline.

    Finally, you can also report directly to the government, most of which have toll free, anonymous hotlines. However, a word to the wise, if you choose to report anonymously, make a careful record of what you reported and to which agency.

    As always, if you have a question, you can seek legal counsel and get an opinion. This can also help to protect you from any negative action.

    I am licensed in New Mexico and Pennsylvania, and therefore any discussion of issues related to other states must considered within that context. In addition, my comments are not intended to create a legal representation but merely to respond to the limited facts presented by the question. Any opinion herein is not meant as a precise statement of legal rights or as a recommendation of any particular course of action. A more complete legal review can be obtained through local counsel.

  3. You received two good answers. I agree that your first step would be to report it to your supervisor or someone at the hospital and let them handle it. And keep your obvious anti-immigrant agenda out of any of your reports or you may lose some credibility.