Analyze the following and identify the fraud and abuse issues that exist. Dr. Pe
ID: 244249 • Letter: A
Question
Analyze the following and identify the fraud and abuse issues that exist.
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, she 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 or not it has already been submitted or not.
Based on the question above, what should Central City do to ensure these types of problems don’t occur in the future?
Explanation / Answer
The main goal to prevent this type of Incidence is to Start Internal Audit. It would be better to promote Auditing once in 2 weeks or a month. Auditing should be done at all departments ( once in a month), and for billing department, twice in a month Appoint billing staff who has knowledge of such scenarios. The hospital should focus training not only to doctors and nurses but also to other staffs, which included billing staffs, so that they are more aware how to treat when a newly appointed doctor joined at a concerned department Only Qualified billing staffs should be appointed Provide a policy book at billing department, so that staffs can go through every week to aware about such scenarios The policy should contain scenarios like this. For ex: Policies to follow, when a doctor whose credential process is pending Investigate, whether Dr. Craig is aware of such scenario including his consent in a particular situation If such incident caught, the management should be aware of this Develop Quality team with the presence of Quality Assurance Manager, who checks the quality of all departments, including Billing department Appoint head of billing department who is aware of all policies and regulations. He/She should educate billing staffs in such scenarios. The billing staffs clarify doubts with their head. All staffs should be aware about medicare and its rules. Provide a platform to clarify their doubts, whenever necessary.