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St. Johns River State College *

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2012

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Medicine

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Dec 6, 2023

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HIM 2012 Chapter 14 Homework 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. Answer the following questions: 1. Name the types of fraudulent billing that Meredith is conducting. She is using a procedure that is giving a higher reimbursement compared to the accurate code. She also bills parts of a bundled procedure as separate procedures for a higher reimbursement. 2. Could Meredith be held liable for these activities? Meredith can be liable for for her actions since she is committing fraud and abuse. 3. Is Dr. Pearson subject to liability although he doesn’t know Meredith is conducting these activities? Unfortunately, Dr. Pearson can also be help liable since he is the main physician, meaning he should be able to maintain all medical records including the documentation of provided services. He should be confirming that the claims are backed up with proper documentation. 4. Once Meredith’s activities are discovered, how should her conduct be addressed by her employer, Central City Internal Medicine? Central City Internal Medicine can establish the following strict compliance program that can assist the physician to avoid fraudulent activiites and ensure submission of accurate medical claims. 5. What should Central City do to ensure these types of problems don’t occur in the future? Central City can ensure these problems won’t happen again by implementing compliance standards as well as practice standards. They can also respond appropriately to offenses and develop corrective actions as well as develop open lines of communication between employees and enforce disciplinary standards through publicized guidelines.
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