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Billing Fraud

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What is the name of your state? IL

My employer is billing fraudulently (billing services not performed in high volume). As a coder (not certified) can I be found liable if they are ever found out? I've been told not to question whether the service was provided or not, to bill it anyway.

Thank You--
 


moburkes

Senior Member
What is the name of your state? IL

My employer is billing fraudulently (billing services not performed in high volume). As a coder (not certified) can I be found liable if they are ever found out? I've been told not to question whether the service was provided or not, to bill it anyway.

Thank You--

You are knowingly entering false information into the computer for payments?
 

mlane58

Senior Member
If you are knowingly entering false information, yes you can be held liabel. You don't get immunity just because your employer is telling you to. Report the idiot and get an honest job.
 

moburkes

Senior Member
If you are knowingly entering false information, yes you can be held liabel. You don't get immunity just because your employer is telling you to. Report the idiot and get an honest job.

Which idiot? The boss idiot, or the coder idiot?
 
Well wasn't that sweet? Clearly I'm not the "coder idiot" since I've caught on to what's happening here. Now I'm doing what a non-idiot person would do, researching my predicament so I can make the right choice.
 

fairisfair

Senior Member
although I agree that if you know what is going on and you are participating, that you might be morally wrong, I do not see how you would be held criminally liable.

Mark, she is a coder (I am assuming medical as she discusses services) how would she be expected to know whether or not a service was performed? She has been given instructions by her employer that she is to code what she is given and not to question those items. And what would be her gain in the practice of incorrect billing?
 

mlane58

Senior Member
although I agree that if you know what is going on and you are participating, that you might be morally wrong, I do not see how you would be held criminally liable.

Mark, she is a coder (I am assuming medical as she discusses services) how would she be expected to know whether or not a service was performed? She has been given instructions by her employer that she is to code what she is given and not to question those items. And what would be her gain in the practice of incorrect billing?

I understand where you are coming from, but having knowledge through my wife who has been an office manager for an ear specialist for many years has seen several coders held liable. If the coder is reading the dictation correctly, then they should know what is appropriate for that code. If the OP is not reading the dication and just taking direction from the doctor then I would tend to agree with you.
 
Hi

This is how I know. The docs have a high volume office ,spending a few minutes with each patient. They are assessing codes that are timed procedures requiring a minimum of 38 minutes per patient encounter. Since I'm also a patient, I know they just aren't skimping on time, they're simply not doing them at all. And some patients have questioned this as well. They have a nice scripted response for this.

I have had discussions with the docs and managers about proper usage of codes and been told "bill it, you know we'll cover it in our documentation" and "don't question what the docs are coding, just bill it". The computer system is even set up so that the docs select one procedure, but the wrong CPT code is tied to it!!! This allows for billing of an extra code per encounter. The office doesn't even have the equipment required for this code.

I've brought this to the big guy's attention as well, he was only irritated at my discovery, certainly not happy!!!! Since I was let go today--no reason given, with a nice monetary termination package, letters of recommendation and a promise to not contest unemployment, I'd say they are trying to get rid of the liability.

Oh by the way, everyone profits rather nicely from this, people are paid according to monthly income. I have no burning desire for revenge, they will get caught in due time, I just want to make sure that I can't be penalized for NOT disclosing this information.

Thank You--
 

lealea1005

Senior Member
Just out of curiosity, are you talking about MD's or DC's? I ask because, in our area, several insurance companies come out to the MD offices for site inspections. They randomly pull several charts and compare coding to documentation. If the office does not meet the standards or is found to be upcoding, the Docs are at risk of losing their contract, and their future claims are scrutinized closely.

It is because of providers like Jobhunting's former employer that the rest of us are subjected to downcoding and decreased payments for legit procedures.

Be thankful you're out of there. It's just a matter of time before the insurance companies catch on.
 

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