Healthcare Medical Insurance Processing Discussion Topic: Billing Audit Scenario

Question

Healthcare Medical Insurance Processing

Discussion Topic: Billing Audit Scenario

You are a lead certified billing specialist working for a large successful internal medicine practice. The practice is comprised of 10 physicians, three (3) nurse practitioners (NP), five (5) medical assistants and four (4) billing and coding specialists (including you). Your office manager has asked you to assist her with the recent Medicare RAC audit that is being conducted on 75 random charts. During your review of the documentation and claims that were submitted, you discover that two (2) of your veteran physicians and one (1) nurse practitioner have been billing for services that were not rendered and or upcoding visits totaling approximately $250,000. What will you do upon discovering this?

Explanation / Answer

As a team leader of a highly qualified team, I would always want that I build a rapport with my juniors in such a manner that they disclose and confide in me. So, in the given case, I would first call the two physicians and the nurse practionner to explain the reason for doing so. I will warn them that it is ethically not correct to tax the individual who are coming for availing the services. I will then give them a warning for not indulging in anything that is unethical. If they do not pay heed to the warnings then I will not have any choice but to terminate them. Although, it will be a loss of the company in terms of losing good and effective physicians and nurses but I, as a leader will not allow unnecessary taxing of my clients because, Client satisfaction and Client delight is the motto in today's corporate world.

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