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A solo-practice provider has been practicing in a specific area for 19 years. At 20 years, the staff, several of whom have been with the doctor since the start, can collect retirement through a contracted vendor. However, due to a diminishing of insurance reimbursement, the doctor cannot keep the doors open any longer. The provider realizes that both her and her employees are unlikely to find employment that will provide for any means of financial security in their aging years. Attempts at marketing and attracting additional clients have been unsuccessful as a result of managed care contracts and preferred provider arrangements that have gone to hospital-based physicians. There are no other options, save one. The provider knows that if she upcodes the visits and charges more, she can keep her doors open and retire in a short 12 months.

In your main discussion post, discuss the current dilemma from the perspective of the provider and from the perspective of the staff. Are there any gray areas to this dilemma? If so, can you understand why a provider would be tempted to upcode? Unfortunately, this dilemma is happening across America. In replying to your peers, evaluate their positions on this dilemma. Did you find common ground?

REPLY TO MY CLASSMATE’S DISCUSSION TO THE ABOVE QUESTION AND EXPLAIN WHY YOU AGREE. (MINIMUM OF 200 WORDS)

                                                         CLASSMATE’S POST

Upcoding occurs when a healthcare provider submits codes to Medicare, Medicaid or private insurers for more serious (and more expensive) diagnoses or procedures than the provider actually diagnosed or performed. Healthcare providers use billing codes to identify the services and procedures that they provide to patients. Each code corresponds to a particular service or diagnosis and reflects the complexity of the work that the healthcare provider did.  Government and private insurers use these codes to determine how much to pay for the services and procedures. When provider’s upcode medical bills for Medicare and Medicaid patients, they cheat those healthcare programs of needed funds (Drabiak & Wolfson, 2020).

Physicians and other healthcare providers deserve to be paid for the medical care they provide, but it is essential that they avoid improper billing practices to steer clear of trouble to maintain a flourishing practice or to ensure they have a successful retirement plan. This solo-practice provider has discovered opportunities enticed by a vendor to help set herself and her employees to work for another year so they can retire comfortably. While they have exhausted all other avenues to attract patients, it is unethical to be deceptive by upcoding or charging fees for services or time spent with patients that have not been rendered.

Upcoding is one of the most costly and widespread types of healthcare fraud. These are not victimless crimes, as they place unnecessary stress on a social safety net that millions rely upon for their basic medical needs. Recognizing the heavy cost of these illegal schemes on the American taxpayer, government agencies such as the United States Department of Justice (DOJ) are enforcing the laws against healthcare providers who engage in upcoding, and has established a reward system to encourage whistleblowers to expose this type of Medicare fraud (Chen et al., 2020).

There is not enough information presented to know if the employers are aware of the next step their boss is about to act upon, but if they encourage the provider to upcode or do this for her they are enabling and promoting the provider’s bad behavior and could face serious penalties right beside with her. If the employees are not involved nor aware, but discover the provider is purposefully entering in the incorrect codes for their benefit, an employee could become a whistleblower and expose her and receive compensation for their action if found the provider was fraudulently charging. Under the False Claims Act, which gives employees and other who know about upcoding a way to report, whistleblowers may receive rewards of 15 percent to 30 percent of the amount the government recovers (Drabiak & Wolfson, 2020).  

It is tempting for providers to engage in this type of behavior, but Medicare and Medicaid fraud is a serious issue that affects both patients and providers. Providers must be aware of the regulations surrounding false claims, kickbacks, and referrals because fraud can occur, whether it is intentional or unintentional. The consequence of upcoding increases the cost of health care for everyone because the government and private payers distribute the cost of healthcare among everyone. If convicted of Medicare fraud charges, healthcare professionals could face serious penalties. Fines might be imposed, the doctor may lose his or her license, and some could even face jail time. Not only is this practice unethical and illegal, but it also can result in negative consequences for the patient. One way is that his/her medical records could indicate a health problem that does not really exist. This may result in the wrong type of care later on (Mackey et al., 2020).

                                                    References:

Chen, Z. X., Hohmann, L., Banjara, B., Zhao, Y., Diggs, K., & Westrick, S. C. (2020). Recommendations to protect patients and health care practices from Medicare and Medicaid fraud. Journal of the American Pharmacists Association, 60(6), e60-e65. https://doi.org/10.1016/j.japh.2020.05.011

Drabiak, K., & Wolfson, J. (2020). What should health care organizations do to reduce billing fraud and abuse? AMA Journal of Ethics, 22(3), E221-231. https://doi.org/10.1001/amajethics.2020.221

Mackey, T. K., Miyachi, K., Fung, D., Qian, S., & Short, J. (2020). Combating health care fraud and abuse: Conceptualization and Prototyping study of a blockchain Antifraud framework. Journal of Medical Internet Research, 22(9), e18623. https://doi.org/10.2196/18623