Please Help Me Decide What to Do
April 23, 2010 12:26 PM   Subscribe

What are the ramifications of insurance fraud?

(I am asking for a friend, even though the post is in first person)

"I work for a private practice doctor's office where I file insurance claims for a doctor. The doctor, my boss, is very hands-off and doesn't actually check the claims beyond checking to see if there is an outstanding debt.

I have worked for the doctor for over a decade, and have had a spotless record. My coworker Amanda, however, stole time and filed multiple fake insurance claims.

Amanda would have people she knew come in for a checkup and then charge the insurance company for a minor surgury, and she would say that the patient prepaid. Then, the patient would get the check in the mail and split the extra money with her.

I just found out she was doing this when another coworker of mine turned her in to the boss. I had no idea any of this was going on.

Amanda thought that I was the one who turned her in, so she called up the boss and left messages saying to look into all my claims, because according to her I am robbing him blind.

The only things I have done is charge my son's checkups as my husbands, since they share the same name and my son did not at the time have insurance.

My boss has not prosecuted Amanda yet, but is probably investigating her claims. My boss is vindictive, and was before all of this happened.

I feel terrible about what I have done. It is eating me up inside.

If this were you, would you admit to it, knowing full well that your boss will prosicute you even though you have had a perfect work record up until this point? Or would you wait and see if he prosecutes you without admitting it?

Other people I know seem to think that I should stay quiet and let this blow over, and that my boss may not find anything. Would you just admit it to get it off your chest and take the possibility of prosecution, or would you keep your head down and try to get away with it? Do you know anyone who this has happened to? How did it work out for them?"
posted by TheArpenter to Law & Government (14 answers total)
 
The ramifications? Well the worst case scenario is "going to jail. Insurance fraud is a crime in 48 of 50 states and because this is likely also Medicare fraud (which can be reported by the public) we're talking potential federal charges.

You need to get a lawyer. Like, yesterday.
posted by valkyryn at 12:35 PM on April 23, 2010


TheArpenter: "(I am asking for a friend, even though the post is in first person)"

It's in the very first line, folks.
posted by Grither at 12:41 PM on April 23, 2010 [1 favorite]


You need to get a lawyer. Like, yesterday.

By the way, here's the standard MetaFilter wiki info about how to go about getting a lawyer.
posted by burnmp3s at 12:49 PM on April 23, 2010 [2 favorites]


You've committed a crime. Regardless of good intentions or its victimless nature, you've committed a crime. You are not capable of evaluating the ramifications or punishment. Along with "lawyer up," the best piece of advice re: "Would you just admit it to get it off your chest...?" comes from The Man Who Wasn't There:
One more thing. You keep your mouth shut. I get the lay of the land, I tell you what to say. No talking out of school. What's out of school? Everything's out of school. I do the talking. You keep your trap shut. I'm an attorney. You're a barber. You don't know anything.
Other people I know seem to think that I should stay quiet and let this blow over, and that my boss may not find anything.

Well, then he also won't find out you have a lawyer on retainer just in case it doesn't blow over.
posted by griphus at 1:00 PM on April 23, 2010 [4 favorites]


I think it's possible that Amanda has faked the records somehow, so that it looks like your friend was committing worse fraud than she. Because it seems like what your friend did, fraud or not, is minor compared to Amanda's crime, and she wouldn't have anything to gain by revealing your friend's. (I don't know anything about insurance fraud, just human nature. Vindictive people can be pretty evil.) If I were your friend, I would admit nothing, but I wouldn't expect it to all blow over either. She needs a lawyer.
posted by zinfandel at 1:07 PM on April 23, 2010


I'm not sure that a lawyer is the best solution to every problem as so many others in MeFi seem to do. But I do think that honesty always pays off. I would not volunteer information ever, but if asked a direct detailed question I would always tell the truth. I'm not sure you committed Medicare fraud.. You should be prepared to pay for services rendered. Beyond that there is FRAUD and fraud. If you were not robbing him blind like your coworker was and can prove it easily I wouldn't worry about this.
posted by Xurando at 1:07 PM on April 23, 2010


FWIW: I have asked and been assured that my friend did not commit and medicare fraud. No one knows yet if Amanda did.
posted by TheArpenter at 1:11 PM on April 23, 2010


I would not volunteer information ever, but if asked a direct detailed question I would always tell the truth.

Unfortunately, "the truth" and "self-incriminating information leading to what may be an unlawful firing" tend to look a whole lot like one another when there's no one around to show you the difference between the two. And there sure is a difference between "FRAUD" and "fraud," and that's what the lawyer is there to discover and, need be, convince the appropriate parties.
posted by griphus at 1:13 PM on April 23, 2010


Boatload of trouble but not as much trouble as Amanda.

It depends on how many checkups too. If it was one or two you can plea bargin.

Oh yea, all insurance companies have their own fraud investigation hotlines/staff who work with state, local, and federal agents.

Like the other's said, your friend needs a lawyer stat!
posted by stormpooper at 1:16 PM on April 23, 2010


I'd come clean with your boss and explain the situation thoroughly. Might save your neck. A lawyer could come after you gauge his reaction.
posted by Hurst at 2:04 PM on April 23, 2010


I'd come clean with your boss and explain the situation thoroughly.

But I do think that honesty always pays off.

Your friend needs to not say another word to you, her boss, or a single other being until she has a long talk with a criminal defense attorney.

There's not even really another reasonable option. Any advice you get to the contrary is terrible and very likely to end poorly for your friend.

Also, I'd anonymize this question (or ask for it to be deleted outright) -- your friend cannot be compelled to testify against herself, but you can certainly be compelled to testify against her.
posted by toomuchpete at 2:20 PM on April 23, 2010 [4 favorites]


The only things I have done is charge my son's checkups as my husbands, since they share the same name and my son did not at the time have insurance.

You've worked for this doctor for over a decade and he won't give your son a free checkup? That is just cold.

With all the records being investigated by the insurance company, they may or may not find anything. Don't talk to anyone before you talk to a lawyer, they'll be able to give you options and help decide on a proper course of action.

But deep down, the only people losing money here are the insurance companies. Forgive me, but I have very little sympathy for them losing what amounts to at most, a few hundred bucks over the health of a child with no insurance.
posted by infinitefloatingbrains at 2:35 PM on April 23, 2010 [1 favorite]


Personally I would also feel terrible because I have a guilty soul and while I can definitely imagine submitting my husband's name for my son's claim, I can also see myself being all nervous and paranoid and eaten up inside if I knew that I had a chance of being found out.

But your friend should keep her mouth shut. She should confess to a priest or a rabbi or a pet or someone who is not her boss and cannot testify against her. It's possible that your friend's boss will halfheartedly investigate Amanda's claims, see that she was wrong about your friend robbing him blind, and move on to Amanda's more egregious misconducts.

It definitely helps that your friend's son and your husband have the same name. And it is worth a consultation with a lawyer, who will probably also tell your friend to keep her mouth shut.
posted by amicamentis at 5:23 PM on April 23, 2010


Lawyer. Now.

The fraud was committed against the insurance company. It's not the doctor is vindictive. It's that the doctor will need to disclose the Amanda's fraud to cover his own butt.

Lawyer.
posted by 26.2 at 7:45 PM on April 25, 2010


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