How could the threat of a government investigation and a criminal court action have been prevented in the first place?

 

How could the threat of a government investigation and a criminal court action have been prevented in the first place?

 

 

Right after obtaining her clinical coding specialist, physician-based (CCS-P) credential, Shirley is hired by a prominent psychiatrist to

provide coding and reimbursement assistance for his billing.  The policy of this office is to assign codes for a œstandard visit that

consists of a 50-minute psychotherapy session unless the physician indicates that a different service has taken place.

Shirley begins to notice that as many as 23 patient claims for a single date of service contain the code for a 50-minute psychotherapy

session.  She also reviews the requirements of the code for œface-to-face services and observes that the physician indicates this service

when only medical record review, medication adjustment, or instructions to nursing staff at the hospital have been performed.  The physician

has a long-term employee (his wife™s sister), Anne, who prepares and submits all insurance claims.  Shirley speaks with Anne regarding her

concerns about the 50-minute visits.  Anne assures Shirley that there is no need for concern, since no services have been denied by Medicare

and since œextra services are commonly bundled into psychotherapy services in this region.

1. What should Shirley™s role be in this situation?
2. Suppose that an investigation of this practice™s billing irregularities is now underway by the Office of the Inspector General.  What

steps should Shirley recommend for this practice?
3.  How could the threat of a government investigation and a criminal court action have been prevented in the first place?

Source:
Harman, LB (2001) Ethical Challenges in the Management of Health Information.  Gaithersburg, MD:  Aspen Publishers, Inc. page 82-83.

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