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Thread: Legal vs ethical dilemma

  1. #1

    Default Legal vs ethical dilemma

    AAPC: Back to School
    Is a billing co legally obligated due to contract with doctor to submit charges to ins co's (esp. Medicare) even though they are aware that the doctor is committing fraud & is on "payment hold" because of an oig audit?

  2. #2
    Join Date
    Apr 2007
    Columbia, MO


    You are submitted claims that you know are fraudulent?? Even if you are under contract you cannot submit claims that you know are incorrect, your choices are send it back for revision, refuse to submit, or correct it before submission.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Join Date
    Apr 2007
    Coastal Coders


    How long has the billing company been a part of this?
    You may want to start looking for another job.

  4. #4
    Join Date
    Apr 2007
    Alexandria, LA


    OIG has a Compliance Guidance document for 3rd party billing companies.
    In part, it says: "If the billing company finds evidence
    of misconduct (e.g., inaccurate claim
    submission) on the part of the provider
    that they service, the billing company
    should refrain from the submission of
    questionable claims and notify the
    provider in writing within thirty (30)
    days of such a determination. This
    notification should include all claim
    specific information and the rationale
    for such a determination.
    If the billing company discovers
    credible evidence of the provider’s
    continued misconduct or flagrant
    fraudulent or abusive conduct, the billing company should: (1) Refrain
    from submitting any false or
    inappropriate claims; (2) terminate the
    contract; and/or (3) report the
    misconduct to the appropriate Federal
    and State authorities within a
    reasonable time, but not more than sixty
    (60) days after determining that there is
    credible evidence of a violation.

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