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Fraud

  1. Unhappy Fraud
    Medical Coding Books
    Has anyone had this experience? A couple of us turned in the boss for fraud, she coded her own visits so that the insurance company does not know what she has. She actually told us what she'd done. Anyhow, they don't seem to believe us, as nothing seems to have been done. Any advice?

  2. #2
    Location
    Columbia, MO
    Posts
    12,840
    Default
    I am not sure I understand what you mean. the physician is coding her own encounters and then submitting the claims herself? What do you mean the insurance does not know what she has? Did she intentionally code and bill for things not performed, or overcode a visit level? This si serious so please be specific.

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    She is the HIM manager, and she did intentionally give herself a different
    DX from the order so that she is not labeled as having what she really
    does have. Then she told us what she did, a couple of times. Some of us
    reported it, but I don't think the other management here gets it.
    Thanks!

  4. #4
    Default
    I would follow the advice given in the recent Coding Edge magazine article about whistleblowing.

  5. #5
    Location
    Columbia, MO
    Posts
    12,840
    Default
    Quote Originally Posted by pscott View Post
    She is the HIM manager, and she did intentionally give herself a different
    DX from the order so that she is not labeled as having what she really
    does have. Then she told us what she did, a couple of times. Some of us
    reported it, but I don't think the other management here gets it.
    Thanks!
    As a patient she coded her own chart with something other than that documented by the physician????? Oh My! Of course you should tell the physician as well as he too could be included in intentional miscoding. I would call the insurance company and speak with a supervisor and even submit a corrected claim. Your clinic is definitely at risk over something like this.

    Debra A. Mitchell, MSPH, CPC-H

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