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?
Im wondering, too!
Legal aspects of health Information management
what is the three types of fruadulent billing Meredith is conducting
Using individual codes, billing under another Medicare number and duplicate claims
Yes
1. The types of fraudulent billing that Meredith is conducting include unbundling (billing procedures using individual codes instead of comprehensive codes), identity theft (billing Dr. Pearson's services under the Medicare number of Dr. Craig), and duplicate billing (submitting a claim more than once if unsure whether it has already been submitted or not).
2. Meredith could be held liable for these activities. Healthcare billing fraud is a serious offense and can be subject to legal consequences, including fines and imprisonment, depending on the jurisdiction and the extent of the fraud committed.
3. Dr. Pearson may not be directly subject to liability if he doesn't know about Meredith's activities. However, if he becomes aware of these fraudulent activities and continues to benefit from them without taking any action to rectify the situation, he could potentially face legal and professional consequences.
4. Once Meredith's activities are discovered, her conduct should be addressed by her employer, Central City Internal Medicine. This can involve conducting a thorough investigation, possibly involving external auditors or legal experts, to determine the full extent of the fraudulent billing and any potential financial damages caused. Once the investigation is complete, appropriate disciplinary actions should be taken, which can range from retraining or supervision to termination of employment. If the fraud is significant, it may also be necessary to report it to the appropriate regulatory and legal authorities.
5. To ensure these types of problems don't occur in the future, Central City should implement robust internal controls and regular auditing processes. This can include periodic audits of billing practices, segregation of duties to prevent any single individual from having too much control over the billing process, and implementing software or automated checks to detect potential fraudulent activities. Regular training and education sessions on compliance and ethical billing practices should also be provided to all staff involved in the billing process. It's important to foster a culture of integrity and ethics within the organization to deter fraudulent activities and encourage reporting of any suspicious behavior.