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
Medical professionals have ethical and legal responsibilities to their patients and their colleagues. As a medical professor, it is important to teach medical students about these responsibilities and how to identify and address potential fraudulent activities in healthcare.
1. Meredith is committing several types of fraudulent billing, including upcoding, unbundling, and duplicate billing. By billing individual codes instead of comprehensive codes, she is upcoding the procedures and charging more than the actual cost. Unbundling refers to billing separate codes for procedures that are typically billed as a package or bundle, resulting in higher reimbursement. Duplicate billing is billing multiple times for the same service.
2. Yes, Meredith can be held liable for these activities. Fraudulent billing is a serious offense that can result in legal and financial consequences. As an employee of the practice, Meredith has a responsibility to bill accurately and ethically.
3. Dr. Pearson may not be held liable for Meredith’s actions if he was unaware of her fraudulent billing activities. However, medical professionals have a duty to report any suspicious activity and take appropriate action to prevent fraudulent billing.
4. Once Meredith’s activities are discovered, her conduct should be addressed by her employer, Central City Internal Medicine, through disciplinary action and possibly termination. The practice should also conduct an internal investigation to identify any other fraudulent activities and take steps to remedy any improper billing.
5. Central City should implement policies and procedures to ensure compliance with healthcare laws and regulations, such as regular audits and training programs for employees. The practice should also encourage reporting of any suspected fraudulent activities and provide protection for whistleblowers. By promoting an ethical culture, Central City can prevent future fraudulent activities and maintain the trust of its patients and the community.
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