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Committing Insurance Fraud - Opal

Posted: Sep 15, 2013

I was a CMT who is now doing insurance billing and coding. Now that I understand what I'm doing, after several months, I realize I'm committing insurance fraud. Basically, the doc I work for is very ethical and is not committing the fraud. It's me. The business is owned by a different doctor who makes the doc I work for perform certain tests. However, the doc I work for refuses to circle the appropriate ICD codes on the superbill that will pay for the CPTs which, of course, is the right thing for him to do. In order to get paid for the claims, I've been entering the ICDs that will pay for the tests, bascially because that's what I was trained to do ("always use this diagnosis with this test"). I've decided I'm not going to do this anymore as it's immoral and illegal, not to mention felonies. Have any of you been in this situation? If so, did you get fired when you confronted your boss(es)? I'd appreciate any advice on how to approach the big bosses with this. Thank you!

Does your good doctor circle - anything?

[ In Reply To ..]
Code what he circles, or ask him the diagnosis for the procedure - reason for procedure, and code that.

Yes, he does - Opal

[ In Reply To ..]
Yes, the doc I work for does circle diagnoses, just not the ones that will pay for the tests. When I ask him, he tells me to "use the usual diagnoses" and will not circle the ones I need because he knows it's fraud and unethical, and he doesn't want any part of it. Basically, he's covering his butt as he's just an employee like the rest of his office staff. I plan on telling him tomorrow that from now on, I'm coding what he circles, knowing full well the claims will be denied. The main doc who owns the business does circle the fraudulent ICD codes. I'm amazed that Medicare and the medical insurance companies have not caught on yet. Surely not every patient, from children to the elderly, can have the same diagnoses! (Most of the diagnoses that pay are diseases of the elderly.) Whatever I do, expect to get fired - fired for having the claims denied, fired for standing up to the doctor who owns the business, and fired for calling him out.

Are you a certified coder? - sm

[ In Reply To ..]
That has a lot to do with this. If you aren't, then you aren't as culpable. If they trained you, you would not know better.

You should begin looking for a new job before doing anything else. If, as you fear, the owner demands the incorrect coding, you will be fired if you confront them. I see no way around that.

The written note needs to match the claim, not just the billing slip. That is what an auditor will look for. The office doctor undoubtedly knows this. The owner will simply say that you did this on your own, so if you have written instructions on what to do, make a copy for yourself and keep it at home.

Do you treat Medicare patients? If so, you can report your employer to them. I think you want to have a new job first. They are probably already aware, since they use statistical analysis to detect patterns of inappropriate billing. Just look up the hotline or whatever when you are ready.

No, not a certified coder - Opal

[ In Reply To ..]
No, I'm not a certified coder. I have applied for several jobs since I started working at this office but apparently am too old, under- or overqualified. I was an MT for 30+ years, am in my 50s, so felt/feel very fortunate that an employer gave me a chance to learn something new. Yes, the insurance coordinator at the main doc's office trained me. All I have for proof are my handwritten (then typed) notes that I made for myself when I was trained. The main doc's father does the bookkeeping, and it is a mess. It never balances at the end of the day. Yes, we treat Medicare patients. Thank you for your input!

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