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Thread: Is it OK to squeal?

  1. #1
    Join Date
    Apr 2007

    Default Is it OK to squeal?

    AAPC: Back to School
    I've got a dilemma. A co-worker, who also happens to be a CPC, provided false information to an insurance company. A claim was billed with "physician A" and the claim processed as out-of-network. The patient was required to meet a deductible rather than a copay. This co-worker sent a "corrected" claim to the carrier under "physician B" stating it was incorrect when first filed. This was brought to our attention by the patient when she received a bill. She states she was told by "co-worker" that she would take care of the denial. We have gotten visit notes that are obviously not written by "physician B". Am I overreacting in thinking this is insurance fraud? I'm afraid that if I address it with her she will state she didn't know she couldn't change a physician (yeah, she really will). Does anyone know of any material that I can present to her and our supervisor that will prove that she would have and should have know this was wrong?? Thanks!

  2. #2
    Join Date
    Apr 2007
    Louisville, KY


    It is not necessary for something to be "known" in order for it to be: A.) Wrong, B.) Fraud, C.) Abuse or D.) a violation of ethics.

    Look into some of the commentary from compliance writers/journalists; you'll see that if this were a court case, the burden of proof would simply be that the co-worker did something inappropriate--not that he/she knew it to be incorrect.

    Just a thought.

    I tend to stay out of these "dodging bullet" issues, but thought I'd weigh in on what you do not have to "prove."
    Kevin B. Shields, RHIT, CPCO, CCS, CPC, COC, CCS-P, CPC-P, CPC-I

  3. #3
    Join Date
    Apr 2007


    That is excellent advice Kevin.

  4. #4
    Join Date
    Apr 2007
    Bettendorf, Iowa


    You'd be amazed what people think they can get away with in the coding world. I hate situations like this, you have to make a choice to be an accomplice by knowing it happened and ignoring it or putting yourself in the middle.

    If it were me...I would find documentation you can print off and take to your co-worker and say "its been bothering me, so I wanted to double check on the policy and this is what I found." Sometimes playing dumb can save face for someone else and they won't be on the defense.

    Take the problem to your coworker first, if you take it straight to your boss it will look like you wanted to get her in trouble and thats not true, you just want her to bill correctly. If she knows someone else is paying attention and won't let her take the lazy way out she may be better about it in the future. If she isn't then take it to your boss, but be willing to stand up for yourself and what is right.

  5. #5
    Join Date
    Apr 2007
    Rochester NY

    Default wrong

    Unfortunately, this is/was wrong of her and common sense should tell her you can't just change it to suit the patient. The patient was wrong to ask. I used to work in billing and I had patients call and ask for our billings to be altered, and I always told them NO. The way it was billed (provided it was indeed correct) is the way it had to stay and the patient would have to pay the copay and/or deductible assigned by their insurance carrier. IF there was an error, then of course it got fixed and legitimatelly rebilled for appropriate payment.

    You can not just go around changing bills because the patient asks you to. If that payer came in and did an audit, the payment would be updated/corrected and the patient would be re-billed accordingly. This billing alteration would be very easy for anyone to pick up on, as you stated that Dr. A signed the report and it was rebilled with Dr B - so it doesn't take a rocket scientist to figure out what happened - especially since there is a paper and/or electronic trail for the charge correction that happened on this account.

    You need to take a stand here, and tell your co-worker what she did was incorrect and don't let her play dumb or bully you. You know, and that makes you just as liable as she is. This information is most likely in your text books from school. I can't think offhand where else you can find it - having a little bit of a brain "toot" here. But I know I have heard it and seen it documented all over. Try the Medicare/CMS website under chart documentation.
    Good luck!

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