Dr. Pearson has recently been hired into the Central City Internal Medicine Group as its fifth physician. He has recently completed his residency and is eager to enter private practice. Dr. Pearson is introduced to Meredith and Dawn, two members of the billing staff for the practice. Unbeknownst to Dr. Pearson, Meredith financially assists the practice in several ways. She bills procedures by using individual codes instead of comprehensive codes, has decided to bill Dr. Pearson’s services under the Medicare number of Dr. Craig (another Central City physician) until Dr. Pearson’s credentialing process has been completed, and habitually submits a claim more than once if she isn’t sure whether it has already been submitted or not.
1. Name the types of fraudulent billing that Meredith is conducting
. 2. Could Meredith be held liable for these activities?
3. Is Dr. Pearson subject to liability although he doesn’t know Meredith is conducting these activities?
4. Once Meredith’s activities are discovered, how should her conduct be addressed by her employer, Central City Internal Medicine?
5. What should Central City do to ensure these types of problems don’t occur in the future?
Expert Solution Preview
Introduction: In this scenario, we come across a new hire in the Central City Internal Medicine Group, Dr. Pearson, who is introduced to the billing staff of the practice. We learn that one of the billing staff members, Meredith, is engaging in fraudulent billing activities. This assignment will answer the questions related to Meredith’s conduct and the liability and responsibility of Dr. Pearson and the employer, Central City Internal Medicine Group.
1. Types of fraudulent billing that Meredith is conducting: Meredith is engaging in several types of fraudulent billing, including unbundling, upcoding, and submitting claims more than once.
2. Liability of Meredith: Yes, Meredith can be held liable for her actions. These fraudulent billing practices are illegal and can result in legal action, fines, and imprisonment.
3. Liability of Dr. Pearson: Although Dr. Pearson doesn’t know about Meredith’s fraudulent billing practices, he may still be subject to liability for the consequences of the fraudulent billing. As a physician in the practice, he has a responsibility to ensure that the billing is done ethically and legally.
4. Addressing Meredith’s conduct: Central City Internal Medicine Group must take appropriate legal action against Meredith for engaging in fraudulent billing practices. Further, it must also review and strengthen its billing procedures and practices to prevent such actions in the future.
5. Preventing fraudulent billing practices: Central City Internal Medicine Group must conduct regular training and education sessions on ethical billing practices for its staff, implement monitoring and auditing systems to detect fraudulent billing practices, and ensure that all billing staff members are properly licensed and certified. Additionally, it must also enforce strict penalties and disciplinary actions against those who engage in such practices.
