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 was 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 the discrepancy you found while matching each patient's medical record with its claim and reimbursement. The claims for office visits of returning patients were submitted using the higher code of consultation. From your capstone experience, you learned that the office visits of returning patients are not generally coded as consultations. It appears then that the practice is upcoding ser. vices 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. DID YOU KNOW? Claim A claim is a request for payment that itemizes services, dates, and costs. Healthcare providers (such as hospitals, physicians, and other practitioners) submit claims to pay- ers (such as Medicare, Medicaid, healthcare insurance plans, and workers' compensa tion). Patients may also submit claims for benefits based on the terms of their health insurance policy. MINI-CASE STUDY QUESTIONS 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 her 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? POINTS TO REMEMBER A profession is a body of knowledge shared by a group of individuals with specialized education and training and common values. Two common characteristics of professionals are possessing systematic knowledge and adhering to professional norms. 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 was 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 the discrepancy you found while matching each patient's medical record with its claim and reimbursement. The claims for office visits of returning patients were submitted using the higher code of consultation. From your capstone experience, you learned that the office visits of returning patients are not generally coded as consultations. It appears then that the practice is upcoding ser. vices 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. DID YOU KNOW? Claim A claim is a request for payment that itemizes services, dates, and costs. Healthcare providers (such as hospitals, physicians, and other practitioners) submit claims to pay- ers (such as Medicare, Medicaid, healthcare insurance plans, and workers' compensa tion). Patients may also submit claims for benefits based on the terms of their health insurance policy. MINI-CASE STUDY QUESTIONS 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 her 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? POINTS TO REMEMBER A profession is a body of knowledge shared by a group of individuals with specialized education and training and common values. Two common characteristics of professionals are possessing systematic knowledge and adhering to professional norms