week 15 chapter 16 reality check billing and reimbursement

For ten years, Juan Garcia has worked as the office manager for Dr. Smith, a local and well-respected osteopath in his community. It was brought to Mr. Garcia’s attention by one of his coders that Dr. Smith appears to be upcoding with some of his services for Tricare patients. Mr. Garcia thought this was impossible as Dr. Smith had a high level of integrity and position of authority in the community. The coder, on the other hand, had coded for four years. She was new and not as savvy to Dr. Smith’s billing practices. Mr. Garcia was not a coder himself, but he did understand some aspects of coding, and especially coding for TRICARE. When his coder brought this to his attention, he brushed her off. Instead of asking her to audit Dr. Smith’s charts, Mr. Garcia decided to hire an outside auditor to review Dr. Smith’s work.

Six months later, Mr. Garcia still hadn’t called in an auditor. Much to his surprise, the Office of Inspector General (OIG) paid a visit to the practice. The OIG removed everything from the premises − records, computers, anything that might prove fraud had occurred with TRICARE billing, and perhaps other billings. This was a very serious situation and Mr. Garcia and Dr. Smith were in a lot of trouble.

The next week, the coder resigned from her position and moved to another state to start working at another office.

At what point did Mr. Garcia need to do something about the potential allegations against Dr. Smith?

Were the actions of the coder right or wrong?

What would you have done in this situation?

For full credit these three questions must be answered in detail with supporting evidence (or insightful thoughts).

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