Analyze the following and identify the fraud and abuse issues that exist. Dr. Pe

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.

Explanation / Answer

Medical Fraud - Among the fraudulent billing carried out by Meredith includes Upcoding where she uses a procedure code that provides a higher reimbursement rate than the code that actually it has to be.

Also she is not verifying whether it is submitted or not and puts forth the claim more than once habitually which she is not supposed to do.

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