Mini case study: Coding Error in Orthopedics

For six months now, you have been an assistant administrator in a large orthopedic group practice. You feel fortunate because your capstone experience as a student in a healthcare management program took place in a similar physician practice. Currently, you are reviewing reimbursements received from Blue Cross. Several large$$federal agencies are based in your city, so many Blue Cross payments are for patients enrolled in the Federal Employee Health Benefits Program. You are confused by a discrepancy that you found while matching patient medical records with corresponding claims and reimburse$-$ments. The claims for office visits for returning patients were submitted using a higher code of consultation. From your capstone experience, you learned that office visits for returning patients gen$-$erally are not coded as consultations. It appears, then, that this practice is upcoding services to fraudulently inflate its reimbursements. You bring your concerns to your boss, the practice$$s CEO, who says, $$Our coders are certified. Plus, our orthopedic surgeons are the best in the area. They only treat the most complex cases, which are equal to consultations. Don$$t worry about it$.$ The CEO then reassigns you to updating the practice$$s strategic plan and tells you to drop the reimbursement review. After thought and preparation, you set up an appointment to meet with the practice$$s$$medical director.

$1.$ What documents would you bring to your meeting with the medical director?

$2.$ What professional standards has the CEO violated?

$3.$ Is it likely that the CEO is licensed?

$4.$ Which credentials$$academic and professional$$could the CEO hold?

$5.$ Would you immediately report the CEO to an association$$s professional standards committee $($or a similar entity that investigates violations of professional standards$)$

$6.$ What laws have been broken? Who should be held responsible?

$7.$ Should you find another job?