Case Discussion
Dr. Pearson has recently been hired into the Central City Internal Medicine Group as its fifth physician. He has recently completed his residency and is eager to enter private practice. Dr. Pearson is introduced to Meredith and Dawn, two members of the billing staff for the practice. Unbeknownst to Dr. Pearson, Meredith financially assists the practice in several ways. She bills procedures by using individual codes instead of comprehensive codes, has decided to bill Dr. Pearson’s services under the Medicare number of Dr. Craig (another Central City physician) until Dr. Pearson’s credentialing process has been completed, and habitually submits a claim more than once if she isn’t sure whether it has already been submitted or not.
1. Name the types of fraudulent billing that Meredith is conducting.
2. Could Meredith be held liable for these activities?
3. Is Dr. Pearson subject to liability although he doesn’t know Meredith is conducting these activities?
4. Once Meredith’s activities are discovered, how should her conduct be addressed by her employer, Central City Internal Medicine?
5. What should Central City do to ensure these types of problems don’t occur in the future?
Once Meredith’s activities are discovered, how should her conduct be addressed by her employer, Central City Internal Medicine?
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1. The types of fraudulent billing that Meredith is conducting are:
- Billing procedures using individual codes instead of comprehensive codes: This is known as unbundling, where separate billing codes are used for services that should be billed as a single comprehensive code.
- Billing Dr. Pearson's services under the Medicare number of Dr. Craig: This is identity theft and fraudulent billing, as Dr. Pearson's services should be billed under his own Medicare number once his credentialing process is completed.
- Habitually submitting a claim more than once: This is known as duplicate billing, where a claim is submitted multiple times for the same service, potentially resulting in excessive payment.
2. Yes, Meredith could be held liable for these activities. Fraudulent billing is illegal and unethical, and individuals engaged in such activities can be subject to legal repercussions, including fines, criminal charges, and loss of employment.
3. Dr. Pearson may not be subject to direct liability since he is unaware of Meredith's fraudulent activities. However, it is essential for him to report any suspicious or unethical behavior to the appropriate authorities or his employer once he becomes aware of it.
4. Once Meredith's activities are discovered, her conduct should be addressed by her employer, Central City Internal Medicine, in a thorough and appropriate manner. This may involve conducting an internal investigation, gathering evidence of the fraudulent activities, and taking appropriate disciplinary actions, which may include termination of employment. Central City may also need to report the fraudulent billing to the relevant regulatory authorities.
5. To ensure these types of problems do not occur in the future, Central City should consider implementing the following measures:
- Conduct regular audits and reviews of billing processes to identify any potential fraudulent activities.
- Provide proper training and education to employees regarding ethical billing practices, including the consequences of fraudulent billing.
- Implement strong internal controls and oversight to prevent unauthorized access to billing systems and ensure proper billing procedures are followed.
- Foster a culture of ethics and compliance within the organization, encouraging employees to report any suspicions or concerns regarding fraudulent activities.
- Stay updated with the latest regulations and guidelines related to billing practices and ensure compliance with them.
- Establish a process for reporting and investigating any suspected fraudulent activities promptly.