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Question for coding fraud

  1. #1
    Question Question for coding fraud
    Medical Coding Books
    Can someone supply me with something in writing regarding coding fraud-I need to prove to my employer that if a coder committs fraud-the coder will get fined and possibly go to jail along with the doctor. If this isn't the case let me know.

    Thanks!
    Michelle

  2. #2
    Location
    North Carolina
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    3,126
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    Maybe this will be a start....(Page 11)

    Begins on page 2 (not sure what type of practice you have though)

    Step Seven: Enforcing Disciplinary Standards Through Well-Publicized Guidelines
    Finally, the last step that a physician practice may wish to take is to incorporate measures into its practice to ensure that practice employees understand the consequences if they behave in a non-compliant manner. An effective physician practice compliance program includes procedures for enforcing and disciplining individuals who violate the practice’s compliance or other practice standards. Enforcement and disciplinary provisions are necessary to add credibility and integrity to a compliance program.
    The OIG recommends that a physician practice’s enforcement and disciplinary mechanisms ensure that violations of the practice’s compliance policies will result in consistent and appropriate sanctions, including the possibility of termination, against the offending individual. At the same time, it is advisable that the practice’s enforcement and disciplinary procedures be flexible enough to account for mitigating or aggravating circumstances. The procedures might also stipulate that individuals who fail to detect or report violations of the compliance program may also be subject to discipline. Disciplinary actions could include: Warnings (oral); reprimands (written); probation; demotion; temporary suspension; termination; restitution of damages; and referral for criminal prosecution

    http://www.oig.hhs.gov/authorities/docs/physician.pdf

  3. Default
    I think what mkees is asking is what will happen to the coder if the practice or Dr tells her to willfully commit fraud.
    If the coder does this...under duress of..... say, losing your job.
    What charges can be brought against the coder?

  4. #4
    Location
    North Carolina
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    That wasn't my interpretation. In any case...fraud, under any kind of pressure, is not worth losing your certification...not to mention all the ramifications that go hand in hand with that. So, if my answer isn't sufficient, someone else can provide their opinion.

  5. #5
    Location
    Duluth, Minnesota
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    alrightly then - my opinion is: if the employer I was working for, even "hinted" at the fact that they wanted me to KNOWINGLY produce fraudulent coding claims AND then had the audacity to want something in writing as proof that people would get in trouble.... plain and simple, I'd quit. (yeah yeah, we all need our jobs and money especially in this economy, I'd still quit, sorry, just no way they could pay me enough to do it)
    EVERYONE knows (or should know) that if anyone knowingly produces fraudulent coding - you will be held responsible for your actions. Key word - KNOWINGLY. That's a lot different than simply making an error and correcting it. (I think most of us have done that, I know I have). We might spend a lot of time on certain claims, thinking we've got the coding correct only to find out the insurance company says it's wrong - was that fraud on our part? NO! is a correction made? YES! anybody go to jail?....nahhh...
    BUT - continue to do it and it becomes a problem.

    Really, how many coders do you know that have gone to jail for fraud? my knowledge is of "one" - in California, a few years back - but it was VERY OBVIOUS KNOWINGLY FRAUDULENT actions on her part - she got what she deserved imo.
    Donna, CPC, CPC-H

  6. #6
    Location
    North Carolina
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    Nicely put, Donna.

    D. The Difference Between ‘‘Erroneous’’ and ‘‘Fraudulent’’ Claims To Federal Health Programs

    There appear to be significant misunderstandings within the physician community regarding the critical differences between what the Government views as innocent ‘‘erroneous’’ claims on the one hand and ‘‘fraudulent’’ (intentionally or recklessly false) health care claims on the other. Some physicians feel that Federal law enforcement agencies have maligned medical professionals, in part, by a perceived focus on innocent billing errors. These physicians are under the impression that innocent billing errors can subject them to civil penalties, or even jail. These impressions are mistaken.
    To address these concerns, the OIG would like to emphasize the following points. First, the OIG does not disparage physicians, other medical professionals or medical enterprises. In our view, the great majority of physicians are working ethically to render high quality medical care and to submit proper claims.
    Second, under the law, physicians are not subject to criminal, civil or administrative penalties for innocent errors, or even negligence. The Government’s primary enforcement tool, the civil False Claims Act, covers only offenses that are committed with actual knowledge of the falsity of the claim, reckless disregard, or deliberate ignorance of the falsity of the claim.
    The OIG is very mindful of the difference between innocent errors (‘‘erroneous claims’’) on one hand, and reckless or intentional conduct (‘‘fraudulent claims’’) on the other. For criminal penalties, the standard is even higher—criminal intent to defraud must be proved beyond a reasonable doubt.

  7. #7
    Location
    Albany, New York
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    456
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    I'm with dmaec.

    Just the fact that someone (your employer) would ask you for proof of ramifications should be a definite RED FLAG.

    I would start looking for another job.
    Karen Maloney, CPC
    Data Quality Specialist

  8. #8
    Location
    Duluth, Minnesota
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    thanks Rebecca you too! I don't think the links you post could make it any clearer! (my favorites list is getting full of your links btw) ! LOL
    Donna, CPC, CPC-H

  9. #9
    Default Coding Fraud
    Thanks for the info, but what I mean is, my employer is NOT asking for the coder to committ fraud, but in the event of an audit that could initiate fines, our agrument is the doctor's say the fine would be against them and not the coders. But I have always been told the coder goes down with the doctor but when googling I culdn't find anything to support the coder getting in trouble except for losing their job. Any insight??

    Thanks!
    Michelle

  10. #10
    Location
    Duluth, Minnesota
    Posts
    1,133
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    the fines will be against them... UNLESS you yourself are KNOWINGLY putting fraudulent coding through. Then, you'll get it too.
    Donna, CPC, CPC-H

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