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?
Expert Solution Preview
1. The types of fraudulent billing that Meredith is conducting include:
– Upcoding: Meredith is billing procedures using individual codes instead of comprehensive codes, which results in higher reimbursement rates.
– Identity theft: Meredith is billing Dr. Pearson’s services under the Medicare number of Dr. Craig, which is fraudulent and unauthorized.
– Duplicate billing: Meredith habitually submits a claim more than once, potentially resulting in duplicate payments for the same services.
2. Yes, Meredith could be held liable for these activities. Fraudulent billing is illegal and can lead to civil and criminal penalties. If Meredith is found guilty, she may be subject to legal actions, fines, imprisonment, or other consequences.
3. Dr. Pearson may not be directly subject to liability since he is unaware of Meredith’s activities. However, ignorance of fraudulent activities does not absolve a healthcare professional from potential liability. It is crucial for healthcare providers to have proper policies and procedures in place to prevent and detect fraudulent billing activities.
4. Once Meredith’s activities are discovered, her conduct should be addressed by her employer, Central City Internal Medicine. The appropriate actions may include conducting an internal investigation, gathering evidence, and potentially terminating her employment. Central City should also consider reporting the fraudulent activities to the relevant regulatory authorities, such as Medicare or Medicaid, to ensure appropriate action is taken.
5. To ensure these types of problems don’t occur in the future, Central City should implement several measures:
– Establish and enforce clear billing and coding policies that comply with legal and ethical standards.
– Provide regular training and education to staff members, including physicians, on proper billing practices and fraud prevention.
– Implement internal controls and audits to detect and prevent fraudulent activities.
– Encourage a culture of reporting any suspicious billing practices or concerns.
– Conduct regular reviews of billing records for accuracy and compliance.
– Stay updated on changes in billing and coding regulations to ensure compliance with current guidelines.
