Higgers, Welcome back to our slash malicious compliance.

In this video, my boss fired me for attending my own mother's funeral, claiming I was doing my job wrong and costing them money.

So I decided to show them what doing my job right actually meant.

The federal government agreed with me to the tune of eight million dollars, and the Reddit malicious compliance title story starts like this.

So.

I had been working at this medical billing company for about three years.

The company processed insurance claims for dozens of medical practices, small hospitals, and urgent care centers across multiple states.

My official title WARS Compliance Analyst, which basically meant I was responsible for making sure the claims we submitted to Medicare, Medicaid, and private insurers were accurate and followed all the federal regulations.

It's actually a pretty important job when you think about it.

Healthcare fraud costs taxpayers billions of dollars every year, and a lot of it happens through fraudulent billing practices, upcoding, unbundling bill for services that were never provided.

That kind of thing.

My job was to catch errors before they went out the door and fleg anything that looked suspicious.

I took it seriously because I genuinely believed in what I was doing.

Protecting the healthcare system from fraud might sound boring, but someone has to do it.

When I started, the company was actually pretty good about compliance.

The original owner had built the business from scratch, and he understood that cutting corners and compliance was a recipe for disaster.

He had seen other billing companies get shut down by federal investigators and he wanted no part of that.

So, yeah, we had real processes, real oversight, and when I flegged something, it actually got addressed.

But then, about a year before everything went down, the original owner decided to retire.

He sold the company to a private equity firm that specialized in acquiring healthcare services businesses.

You can probably see where this is going already.

The new owners brought in their own management team, and suddenly everything was about maximizing profit margins and hitting quarterly targets.

The news SEO was this guy who had never worked in healthcare billing before.

His background was in some kind of text startup that had something to do with logistics.

He had no clue about CMS regulations, no clue about the False Claims Act and no clue about any of the stuff that actually mattered in our industry.

But he had a lot of opinions about how we were leaving money on the table and how we needed to be more aggressive with our billing practices.

At first, I tried to work within the system.

When I saw claims that looked problematic, I flagged them like I always did, and when the new management pushed back and told me to approve them anyway, I documented everything.

I kept detailed records of every conversation, every email, every instance where I raised concerns and was overruled.

I had learned from previous jobs that documentation was your best friend when things were in sideways.

The problems I was seeing were serious, though.

We had account managers who were pressuring the medical practices we worked with to upcode their services.

If a patient came in for a basic office visit, they would suggest billing it as a comprehensive examination to get more money from Medicare.

We had coders who were unbundling procedures that should have been built together, turning one charge into three separate charges.

We were billing for follow our visits that never happened, and the pattern was clear.

The new management was systematically inflating claims to boost revenue, and they were using the medical practices trust in us to do it.

One particular incident stands out in my memory.

One of our client practices was a small family medicine clinic that primarily served elderly patients on Medicare.

Their billing had always been straightforward and clean.

After the new management came in, I noticed their average reimbursement per visit had jumped by almost forty percent in just three months.

When I looked into it, I found that the account manager assigned to them had been helping them reclassify their visits to higher paying codes.

I pulled the charts for a random sample of patients and compared them to the billing codes.

A patient who came in for our blood pressure check and medication refill was built as it's a comprehensive preventive examination.

A routine follow up for a stable chronic condition was coded as if it required complex medical decision making.

It was textbook upcoding, and it was happening across dozens of accounts.

When I flagged this particular account for review, the account manager came storming into my office, demanding to know why I was interfering with her clients.

She said the practices were happy with the increased revenue and I was just going to ruin the relationship.

I explained that the coding didn't match the documentation and that submitting these claims could expose both of us and the practice to federal fraud charges.

She told me I was just being paranoid and that everyone does this.

I escalated it to the CEO, and his response was that I needed to be a team player and stop creating friction with the account managers.

And he said the practices were all clients and if they were comfortable with the billing, it was not my place to second guess them.

When I pointed out that it was literally my place to ensure their compliance with federal regulations, he told me I was missing the big picture and that my attitude was becoming a problem.

I then brought my concerns to the director of Operations, who was one of the original owners hires.

He agreed with me that things were going in a bad direction, but he said his hands were tired.

The new owners had made it clear the hitting revenue targets was the only thing that mattered for them, and anyone who couldn't get on board could find another job.

He told me to keep my head down into my best, but he was clearly defeated.

Around this time, my mom got sick.

She had been having some health issues for a while, but we thought it was manageable.

Then she got diagnosed with pancreatic cancer and the doctors told us it was already stage four.

They gave her maybe six months if the treatment went well.

Spoiler alert, it didn't go well.

This was my mom, the woman who raised me, who worked two jobs when I was a kid to make sure I had everything I needed, who drove six hours each way to see me graduate from college, who called me every Sunday without fail, just to hear how my week had been.

Finding out that she was dying was like having the ground pulled out from under me.

I talked to my supervisor about the situation and ask about taking intermittent leave under FMLA to help take care of her.

He was understanding and told me to do what I needed to do.

Over the next few months, I would fly out to see her every couple weeks, usually taking long weekends.

I worked remotely when I could, and kept up with my responsibilities as best as I could given the circumstances.

The treatments were brutal.

Chemo made her so weak she could barely get out of bed.

My dad was trying to take care of her on his own, but he was in his seventies and it was wearing him down.

I tried to be there as much as I could, but I was also trying to hold onto my job because we needed their health insurance.

During this time, I noticed that the new management seemed annoyed by my absences.

They never said anything directly, but there were comments about how some people were more committed than others and pointed questions about when I would be fully back to working normal hours.

I documented these interactions too, just in case.

And then one day I got a call from my dad.

Mom had taken a turn for the worse and the doctors said she probably only had a few days left.

I immediately told my supervisor I needed to leave, and he approved my PDO request on the spot.

I flew out that same day, and here's where things get complicated.

While I was gone, the director of operations got fired.

He had been one of the last holdouts from the old regime, and the new CEO finally decided he needed to go in his place, they promoted this absolute nightmare of a human being who had been working as one of the regional account managers previously.

This guy had been one of the worst offenders when it came to pressuring practices to upcote, and now he was in charge of the whole operation.

I found out about this while I was sitting in the hospital with my mom.

Someone from work text at meet to tell me what happened.

At that moment, I honestly didn't care.

My mom was dying and that was all that mattered.

My mom passed away on a Tuesday morning.

I was holding her hand when it happened, and my dad was on the other side of the bed.

It was the hardest moment of my entire life.

Afterwards, there was so much to deal with, funeral arrangements, notifying relatives, going through her things, supporting my dad, who was absolutely devase.

Stated they'd been married for over forty years.

The funeral was scheduled for that Friday.

I'd already told my supervisor I would need about a week and a half total to handle everything, and he had approved it.

Before he got fired, and I had the approval in writing, meaning my PTO was legal.

I figured that would be the end of it, but it was not the end of it.

The day after my mom's funeral, I got a call from the new director of operations.

Keep in mind I had never actually spoken to this guy before because he got promoted while I was gone.

He called me on a Saturday, the day after I buried my mom, and the first few words out of his mouth were asking when I was planning to come back to work.

I explained that I had approved PTO through the following Wednesday, which was what my original supervisor had signed off on, and he said that was unacceptable because there was a lot of work that had piled up in my absence, and my extended leave was apparently costing the company money.

I reminded him that I was dealing with my mom's death and at my leave had been properly approved.

His response was something like, I understand that, but we all have personal issues.

The company cannot stop operating because of your family situation.

I need you back by Monday.

I was stunned.

I told him that was not possible because I was still out of state.

Helping my dad, and there were still things that needed to be handled, and he said he would make a note of my refusal to return and that we would discuss it when I got back.

That conversation set the tone for everything that followed.

When I finally returned to the office about a week later, I was called into a meeting with the new director of Operations and someone from HR.

I figured they were just going to reprimand me for the extended absence or something, but what actually happened was much worse.

The directors set across from me with this smug look on his face and told me that my performance issues had been reviewed during my absence.

He said that a comprehensive audit of my work had revealed that I'd been rejecting legitimate claims without proper justification, and that my excessive caution was costing the company hundreds of thousands of dollars and lost revenue.

I could not believe what I was hearing.

The claims I'd rejected were claims that I determined were potentially fraudulent on none compliant with federal regulations.

That was literally my job, but according to him, I'd been doing my job wrong.

This whole time, and my extended absence had given them the opportunity to review my work and see just how much money I'd been leaving on the table.

He then slid a piece of paper across the table.

It was a termination letter, citing performance deficiencies and failure to meet departmental standards.

The HR person sat there, looking uncomfortable, but didn't say anything.

I asked if this was about me taking time off for my mom's funeral.

He denied it and said this was purely about my job performance.

I asked why if my performance had been so deficient, I had never received any written warnings or been placed on any kind of performance improvement plan.

He said the ordered results spoke for themselves, and that the company was within its rights to terminate me for cause.

But I knew exactly what was happening.

They were firing me because I'd been an obstacle to their fraudulent billing practices, and my absence had given them the excuse they needed to get rid of me.

By framing it as a performance issue, they thought they could have any legal liability for firing someone who had just taken bereavement leave.

I was angry.

I was grieving, and I was exhausted, and something inside me just snapped.

He had said I was not doing my job correctly and that my caution was costing the company money.

Also that I was rejecting legitimate claims.

Fine, if that's what they wanted to believe, then I was going to show them exactly what doing my job correctly actually looked like.

Here starts the reason why I posted this on the r slash malicious compliance supreddit.

See.

Over the years, I had kept meticulous records of every sketchy claim that management had overruled me on.

Every time I flagged something as potentially fraudulent and was told to approve it anyway, I made a note of it.

I kept copies of emails where supervisors told me to be less conservative with my reviews.

I had spreadsheets documenting patterns of upcoding and unbundling and across our client accounts and fraud.

I even had recordings of a couple of meetings where the new management openly discussed strategies for so called maximizing reimbursement rates and waste that any compliance professional would recognize as code for fraud.

I had originally collected all this info.

Because I wanted to protect myself if the company ever got investigated.

I figured if the Feds came knocking, I wanted to be able to show that I'd raised concerns and had been overruled.

But now I had a different use for it.

The day after I got fired, I started putting together everything I had because, if you remember, Boss told me I wasn't doing my job correctly, so I decided to do it correctly for once.

It took me about two weeks to organize it all into a comprehensive package.

I documented specific claims that had been submitted fraudulently, identified the patterns across multiple client accounts, and provided the internal communications showing that management was aware of and directing the fraudulent activity.

Then I filed a complaint with the Department of Health and Human Services Office of the Inspector General.

For those who don't know, the OIG is the federal agency responsible for investigating healthcare fraud.

When you hear about billing companies getting hit with massive fines or people going to prison for Medicare fraud, the OIG is usually involved.

They have the authority to conduct audits, subpoena records, and refer cases for criminal prosecution.

I also filed a separate complaint with my state Attorney General's office since some of the effected practices were in state providers, and I consulted with an attorney who specialized in whistleblower cases under the False Claims Act.

Under the FCA, private individuals who report fraud against the federal government can receive a percentage of any money recovered.

It's called a quittam action.

I wasn't sure if anything would come of it, though I had heard stories about whistleblower complaints getting buried or taken years to investigate.

But I'd done everything I could, so I tried to move on with my life.

I found a new job at a different company within a couple months, and the new place was smaller but had a completely different culture.

They actually valued compliance and understood that doing things the right way was better in the long run than cutting corners for short term profit.

I focused on helping my dad adjust to life without my mom.

He was lost without her.

They had been together since high school, and he didn't know how to be alone.

I flew out to see him every few weeks, helped him sort through my mom's things, and made sure that he was eating and taking care of himself.

It was hard, but it also helped me process my own grief.

I tried not to think about the people at my old company who had treated me so horribly during the worst time of my life.

Sometimes I would wake up in the middle of the night still angry about that phone call the day after my mom's funeral.

Other times I would feel guilty for not just letting it go and moving on.

But mostly I just waited and hoped that the complaint I filed would actually lead to something.

Then about eight months later, I got a call.

The investigation had found what they described as systematic and pervasive fraud in the company's billing practices.

My documentation, I'd been instrumental in identifying the scope of the fraud and the individuals responsible.

The attorney told me that my records had essentially provided them with a road map.

The emails showing management directing employees to approve questionable claims, the spreadsheets tracking the patterns of upcoding across client accounts, and the recordings of meetings where executives discussed aggressive billing strategies.

All of it had been verified and expanded upon through subpoenas and additional investigation.

They were preparing to take action and wanted to interview me as a witness.

I spent several hours with federal investigators going through everything I had observed during my time at the company, and they asked detailed questions about specific accounts, specific claim specific conversations.

It was exhausting, but also validating someone was finally taking this series.

What followed was a complex legal process that I cannot go into too much detail about because some aspects are still confidential, but I can tell you the outcome.

The company was hit with civil penalties under the False Claims Act, totaling just over five million dollars, and they also had to pay around two point five million dollars to settle related claims with several state medicaid programs.

On top of that, they were required to enter into a corporate Integrity Agreement with the OIG, which meant they would be under federal supervision for five years, with regular audits and mandatory compliance training.

The costs of implementing and maintaining that oversight were estimated at several hundred thousand dollars per year.

Several of the medical practices they worked were terminated their contracts once the news got out, because nobody wants to be associated with the company that just got busted for Medicare fraud.

Their reputational damage alone probably cost them millions more and lost business.

The new CEO, who had orchestrated the whole thing, he ended up being excluded from participation in any federal healthcare programs.

That's basically a death sentence for your career in healthcare administration.

Last I heard, he had quietly resigned and the company was trying to rebuild under new leadership.

The director of operations who had fired me, the guy who had called me the day after my mom's funeral to tell me I needed to come back to work.

He was named individually in the government's findings as one of the people who had directed the fraudulent billing practices.

He's facing potential criminal charges, though I don't know the current step of that.

I hope he thinks about that phone call every single day.

I hope he remembers that what he said to someone who had just buried their mother.

I also hope the consequences of his actions follow him for the rest of his career.

The account manager who came into my office, demanning to know why I was interfering with her clients.

She was also named in the findings, and she doesn't work in healthcare anymore.

Good.

I still think about my mom every day.

She was a nurse for thirty years before she retired, and she always talked about how important it was to do the right thing, even when it was hard, even when it would be easier to look the other way, even when everyone else was telling you to just go along with it.

She would have been proud to know that her son did not let a bunch of corporate fraudsters get away with cheating the healthcare system she had dedicated to her life too.

Mom, this one was for you, added since a lot of people are asking, yeah, I'm doing better now.

The grief doesn't go away, but it gets easier to carry.

My dad is doing okay too.

We check in on each other regularly.

And the next one is another malicious compliance story, which is titled Mystery Shopping Nonsense.

And if you enjoy them compliance stories, please don't forget to like the video since that helps me tremendously.

Years ago, when I worked at a major chain convenience store, we had mystery shoppers hired by corporate that would come in and secretly evaluate the store.

Employees pay depended on these evaluations.

I worked in over night shift ten pm to six am alone.

That's important to say because the mystery shopper evaluation list included S and I things like hot fresh coffee, horola, grill full, etc.

Not having them would cause you to be dog points and thus not get raisers.

Now, if you ever worked this kind of job, you know that it's just silly during those hours of the night when they are a few customers.

The idea is to balance availability against waste.

But after two rounds of my day, coworkers getting raises and I didn't because per store policy, I didn't make extra coffee or roller grill items during the night.

I spoke to my boss about it.

I understand that this is corporate policy, and I also understand that our store policy is to not do this at night.

So what can I do as a night shift worker to get a better evaluation?

Something along those lines and not adversarial or anything.

But the boss told me just make sure you get full points on every line.

That's your only job, and handed me another evaluation list to study.

Okay q malicious compliance.

For the next couple of weeks, I made sure to make fresh coffee decaf and regular roast at ten PM when I got to work, and fully stocked the roller grill, hot dogs, haulapenno sausage, stocks taketos.

And then at midnight, when exactly none of this stuff had actually sold, I closed the doors and went to stock the coolers.

This took around an hour, and it's just something that is done on night shift.

So at one AM I would then toss all the roller grill items and pour the coffee down the drain and make two fresh pots and restock the grill and reopen the doors.

Then at four I would dump it all and make fresh again.

Because it had been there for two hours.

The boss called me in and told me as long as I got tens and all the other items, I would be getting my rais along with everyone else from then on.

Just for Christ's sake, stop wasting one hundred dollars per night of stuff that doesn't sell.

No problem, boss, Thanks too bad you didn't notice the issue until it cost your bottom line.

And the next one is a malicious compliance story that is titled malicious Compliance on boss led to new job and him being fired.

Nearly thirty years ago, I worked for the US national sales company for a major automotive brand.

I was in product planning, working on the launch of new model vehicles, but was junior level at the time.

My boss was a real hard ass on things and was the type that when he did something wrong then it was someone else's fault, or if it was a good thing that happened, he would take all the credit.

So one Friday, he dumped in my lap that a shipment of wheels and tires had to be sent to Europe for following Monday as part of a photo shoot.

This was the same trip that he had previously denied my travel request to support the event.

Also, he knew about these wheels and tires a week or more prior, and I think he was trying to make me look bad by dumping it on me last minute.

And when I asked him about how I was supposed to get these packed and shipped for arrival in two days, he told me to just get it done and not to bother him with the details.

Further, he wanted that wheels and tires back asap after the photo shoot, so then I triggered malicious compliance, then the flight to Europe and took the weirs and tires as oversized luggage.

I then rented a vent, collected the weirs and tires and took them to the photo shoot.

I took care of business, hung around for the next two days, and then took the weirs and tires back with me on the return flight on Tuesday morning.

What was so sweet was that the executives on sites were very impressed by my dedication to make the photo shoot a success.

Apparently, one of the executives send a note to my boss praising my support and making the event work.

To say my boss was pissed at me was an understatement.

However, what he could do but take the credit as his plan.

Shortly after this, I was offered the role of as vehicle manager and corporate Communications Group, which I gladly took, even though my boss tried to prevent it.

My former boss was let go about four months later, apparently he had no one else to blame him for his best offs.

And yet, guys, thank you for watching.

I will see you again tomorrow.