How to Address Healthcare Fraud in Your Agency

Miscoding on the Billing Forms Discussion Board

The fundamental basis for auditing Medicare and Medicaid billing is that the services provided are confidential, patient privacy must be protected, and the written word of the provider is the record of service provision upon which a review must be initiated (Harris, 2007). Auditing, however, must extend beyond the written record to establish that the services were actually provided to the patient or client and that the services were rendered according to the conditions described in the provider's written record (Harris, 2007)

As the practice manager, I would remind the physician that every employee has a duty to cooperate and a duty of loyalty to the employer. And I would explain that these duties obligate employees to comply with reasonable directions from their employers during an internal investigation. The employee should be party to a conversation that an internal investigation may or may not commence based on the information provided, however, not providing information and cooperating with my word as a practice manager will not alter the course of the next steps that will be taken.

Since every healthcare organization, including -- presumably -- DOCS RU.S. -- has a Compliance Program and a Compliance Officer according to the DHHS OIG published in 1998, the matter will be discussed with the Compliance Office (Murphy & Vandenberg, 2003). The physician will be reminded of the conflict of interest (COI) document that she ostensibly signed, and there is an expectation that she has conducted her practice according to that COI and in compliance with the required billing stipulations for Medicare and Medicaid (Murphy & Vandenberg, 2003.

Assuming an investigation will be conducted, the main priority at the beginning is to review the match between the numbers of tests or procedures, the costs permitted, and the resultant revenues generated by the provision of care (Harris, 2007). During the investigation, I would review the policies and procedures of the DOC RU.S. with the employee, and also to ensure that any perceived violations are established in policy and procedures guidelines (Murphy & Vandenberg, 2003. The perception is that the offense has been on-going, and I would need to document this in a clear audit trail (Murphy & Vandenberg, 2003. All of the pertinent information will need to be written and summarized in a report that will be given to the appropriate authorities (Murphy & Vandenberg, 2003. The investigation will result in a finding of fraud, no fraud, or no conclusion. (Murphy & Vandenberg, 2003 Regardless, all findings must be supported by detailed facts (Murphy & Vandenberg, 2003. The issue of public relations and the impact of disclosing any fraudulent activities to the appropriate regulatory agency or criminal agency must be considered (Murphy & Vandenberg, 2003. DOC RU.S. should have a process for dealing with issues of this type and it should be documented in the policies and standard operation procedural guidelines.