Consequences of Fraudulent Billing
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.
- Name the types of fraudulent billing that Meredith is conducting.
- Could Meredith be held liable for these activities?
- Is Dr. Pearson subject to liability although he doesn’t know Meredith is conducting these activities?
- Once Meredith’s activities are discovered, how should her conduct be addressed by her employer, Central City Internal Medicine?
- What should Central City do to ensure these types of problems don’t occur in the future?
- Meredith is engaging in several types of fraudulent billing, including unbundling (billing for individual codes instead of comprehensive codes), upcoding (billing for a more expensive service than was actually provided), and double-billing (submitting the same claim more than once).
- Yes, Meredith could be held liable for these activities. Fraudulent billing is illegal and can result in fines, penalties, and even criminal charges. Meredith could also face disciplinary action from her employer, including termination.
- Dr. Pearson may not be subject to liability if he did not know about Meredith’s fraudulent activities. However, if he becomes aware of the activities and fails to report them or takes part in them himself, he could be held liable.
