Effectively Submit an Ethics Complaint
Understand the process for when you witness an AAPC Code of Ethics violation.
If you believe an AAPC member has acted contrary to AAPC’s Code of Ethics, detail the substance of the complaint by including the information requirements below, and forward the information to the Ethics Committee via e-mail: firstname.lastname@example.org.
The complaint should include:
- The name of the member or members who are alleged to have violated AAPC’s Code of Ethics.
- The AAPC member identification number of the member(s) who committed the alleged violation (if known).
- A detailed description of the conduct you believe violates AAPC’s Code of Ethics. Minimal details should include what happened, when it happened, and where it happened. Provide the identity of others who might corroborate the allegations.
- Information/documentary evidence supporting the allegations of misconduct. In cases where the conduct violates a statutory provision of the law, a certified copy of the final judgment from a court of competent jurisdiction or administrative agency is required before the Ethics Committee can proceed. As an example, allegations of fraud must be supported by either a civil or criminal court judgment that is not subject to appeal. Allegations that the member violated HIPAA must be supported by a final determination by the Office of Civil Rights.
- Whether you wish to remain anonymous.
Complaints Are Handled
The Ethics Committee investigates submitted complaints based on the information and evidence presented. The committee does not conduct factual investigations and cannot make determinations regarding whether the alleged conduct violates a state or federal statute or regulation. It’s the responsibility of the complainant to provide sufficient evidence of the misconduct for an ethics case to proceed. Mere allegations of misconduct will, in most cases, be dismissed when additional supporting evidence is not provided.
If a complaint demonstrates a credible, prima facie (evident) violation of AAPC’s Code of Ethics, the committee chair will appoint one of the Legal Advisory Board members of the Ethics Committee as the investigating member of the case. The investigating member is responsible for providing the accused member with a Notice of Complaint, which affords the member the opportunity to submit a rebuttal statement and evidence to support their response. Once that information is received, the investigating member determines whether the information warrants submission of the matter to the Ethics Committee for a hearing. When a hearing referral to the committee is not justified by the evidence submitted, the complaint is dismissed, and the complainant and member are notified. When a hearing referral to the committee is warranted, the chair is responsible to schedule a hearing at a time convenient to all committee members. In most cases, hearings are held within 60 to 90 days. Following the hearing, the complainant and the member are notified of the committee’s determination.
Michael D. Miscoe, JD, CPC, CASCC, CUC, CCPC, CPCO, CPMA, is president-elect of AAPC’s National Advisory Board, serves on AAPC’s Legal Advisory Board, and is AAPC Ethics Committee chair. Miscoe has over 20 years of experience in healthcare coding and over 18 years as a forensic coding and compliance expert. He has provided expert analysis and testimony on coding and compliance issues in civil and criminal cases and represents healthcare providers in post-payment audits and HIPAA OCR matters. He is a member and past president of the Johnstown, Pa., local chapter.
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