Wiki Legal Obligation vs Culpability

[SHERRYDUDLEY]

I am concerned about some documentation issues with the practice I just left under not so great terms. I don't want to seem vindictive by reporting them to Medicare but at the same time my name is attached to charts with OBVIOUS fraudulent charges. Specifically with dx code V15.89. I tried to educate them to the fact that Medicare only covers a gyn/pap exam every year for 5 high risk reasons (ONLY 5 specific reasons)but they standardly put the high risk code V15.89 on EVERY claim if the pt has had a gyn/pap exam within the last two years because they know it won't be paid otherwise. A claim was denied as pt's resp and when I questioned why it was filed with a GA modifier when there was no ABN on file and informed them we couldn't bill the pt with no ABN I was told to resubmit it with the V15.89 so it would be paid. AGAIN I specifically told them the pt did not have any of the 5 high risk issues documented so that was fraudulent and I was told that I was wrong and the fact that she was postmenopausal was considered high risk by the doctors. I have copies of e-mails that support the fact that I tried to educate them but I'm wondering in the future if there is a Medicare audit will my career possibly be affected negatively?? *Is the fact that I opposed in writing enough to protect me from culpability? *or am I REQUIRED by law to report them to Medicare or the OIG?

 

[mitchellde]

So it looks like you knew it was wrong when the claim was billed and you billed it incorrectly anyway. This makes you liable for what you knowingly billed out. Several years ago the AAPC ran several articles on coder liability. One statement by the attorney was that if you know it is wrong and you have educated the staff and it continues then you have an obligation to report it. Also if you know it is wrong and you continue to bill it out, even though under orders by management, then you are still liable. I would consult an attorney versed in healthcare law.

 

[SHERRYDUDLEY]

No, I didn't bill it originally

No, I didn't bill it originally. I worked the claims from the back end. I did appeals and problems. So I found the issues after the fact BUT if it came across my desk then I accessed the chart at some point and there will be a record of that. So I guess my question is more about "knowing" it was fraudulent AFTER THE FACT and my legal responsibilities to report it... as well as protecting myself legally and my career if there is a future audit.

I am also concerned about getting a "reputation" as a whistle blower and other practices not wanting to hire me.