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jenn13088

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If I and another individual, who hold the titles of Chief Quality Officer and Administrator, audit our practices inpatient/outpatient coding and find that our inpatient coding is way below par-but the Practice decides to only provide an educational in-service and not re-audit for awhile, would we be held responsible for knowing this information and not reporting/re-auditing if we had any future audits from a RAC or insurer? I'm concerned with the "once you know there is a problem, you have knowledge that must be fixed." How can we protect ourselves from the Practice's decision?

Thanks!
Jennifer
 
Document your findings and send them up the chain. I would suggest you do this via the e-mail so you can have proof of filing (no pun intended). This should cover you because you found the problem and passed it on to the CEO or whom ever your supervisor is.
 
That's what we are afraid of. Since we have knowledge that the coding is incorrect, we feel that our the original audit should be expanded and done within 30 days from the educational session. The worst part is my direct supervisors are the COO and the physicians. Not all of the physicians are aware of the decision made by the COO/Corporate Compliance Officer and the Clinical Compliance Officer/1 of our MDs. I beleive all parties should decide.
 
I have a meeting with the COO/CCO and the Clinical Compliance Officer tomorrow. I hope they see my side of things and change their minds. Wish me luck!
 
Interesting

I hope your meeting today will have a positive outcome.

From my interpretations of the CMS guidelines, it's not that you have to correct a problem or issue once it is discovered, but if you fail to correct and the failure does involve inappropriate payments from Medicare or another government payers, those providers receiving the inappropriate payments could be subject to additional penalties and possibly other corrective actions.

I guess it goes without saying that events you have described are how the majority of whistle-blower cases are discovered. The employee discovers inappropriate actions and/or payments, follows the procedure for reporting within the organization, but nothing changes. That employee reports the issue to the government authorities, and they investigate to determine whether actions should be brought against the provider.

If possible, I hope you let us know the outcome of your meeting today.
 
mdunn said:
Not necessarily, I have always been told that if you are a aware of a problem you should let you superior know and if the problem is not corrected you are to quit or report them. I know that is really hard to digest because we feel like we can't just up and quit our jobs. I know someone that found a problem within her company and repeatedly reported it to her superiors via email and in the end when an audit happened the OIG found her emails and she was the one fined.....thousands of dollars.
Click to expand...

I find this very interesting. Actually, very scary to be honest. So what was the basis of going after her alone? If at all possible I would really appreciate more details about what happened. I am dealing with lots of incorrect things. I report them to the appropriate people, but I ultimately have no power to change most of them. Which I would imagine many coders/auditors are in the same boat as me when it comes to authority. I find, I advise, I correct what I see, but many times I find the same thing again and again and again everytime I look. Your post is making me think I could be hung out to dry due to the inaction of others.

Laura, CPC, CEMC
 
Well, after an hour and a VERY intense conversation, I convinced them to let me pre-audit all admissions and consults for a month to ensure that the docs are coding appropriately. I have to provide an education in-service first and then follow-up with each provider who is deficient. A much better response today than what the original plan was!! :)
 
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