Reference no: EM132307584

Discussion :

1. The medical assistant committed fraud by falsifying ICD-10-CM and CPT codes to get a greater reimbursement from insurers. Unfortunately even though the physicians was not aware of what was going on and was a victim as well he is held liable. When fraud happens the facility suffers as whole and everyone is at guilt. The physician can lose its license as well as the facility. It is very important to hire an outsider to conduct audits on a monthly or annually basis to protect them self from situation like this. It can also help if you have more than one person doing the billing.

2. Falsifying lCD-10-CM and CPT codes to increase reimbursement from insurance companies and the government is considered "upcoding." Upcoding is a violation under the False Claims Act and can potentially be subjected to a civil lawsuit, damages and penalties. In this case, the medical assistant was defrauding the insurers without the provider's knowledge which would make the provider a victim. The provider may be held liable but he or she would really have to prove that they were not aware of what was taking place.

Many providers find themselves in situations like this because they cut cost by hiring medical assistants and billers to handle their medical claims instead of hiring detailed and compliance driven certified professional coders who are trained on the legal and regulatory requirements in healthcare. Hiring an auditor to conduct daily audits could also alleviate these problems from occurring. Most great cpc's are trained to audit and know the compliance requirements but don't have the credentials. Some have multi certifications in all three as well as a variety of specialties making them a prominent force.

3. According to this situation i believe the criminal act the physician committed would be False Claim Act and Health Insurance Portability and Accountability Act ( HIPAA ) would be there to see this claim through. Since this physician is falsifying information and pocketing the difference, the physician is committing the False Claim Act which is knowingly presenting a false claim for payment and the physician is also conspiring to defraud the government for payment from Medicare. HIPAA is this to see that frauds like this physician is dealt with in the right forum and the right actions are given .

4. Even though the physician doesn't have an idea of what his medical assistant is doing with the ICD 10 and CPT codes in order to get some money for herself, the physician will be involved in this case. The reason why the physician will be involved is because the office is under his name and he runs because of his license so everything done right or wrong will be under his name and he can definitely can go to jail because of what unless there find proofs that it was the medical assistant who was doing fraud. Physicians need to hire a proper staff and certified professionals in the area to manage the office and to keep audits and avoid situations like this.