Grant-Kels, Kim, & Graff (2016) in their article discuss and analyze a case scenario of a patient Dr. TH who is concerned that over the course of time she has been visiting large multispecialty health care facility in order to manage her hypertension and hypercholesterolemia, the internist has always coded 99214 for all visits to each of the two physicians involved. Apparently, Dr. TH has worked in the medical sector and is familiar with the coding techniques and she therefore makes a decision to inquire from the practice manager of this facility who happens to have worked with Dr. TH at some point. On this, she is informed that the facility usually codes for complex and simple cases in the same manner which according to DR. TH constitutes unethical coding practices. In essence, that would mean that the facility receives reimbursement for simple cases in the same way and within the same cost range that it receives for the complex cases.
Apparently, this is an issue that seems acceptable within this facility and it could be described as a case where colleagues have colluded to receive unwarranted reimbursements for services not actually offered. Across the options available for Dr. TH in this scenario, is to quit the practice setting as a client; which does not actually resolve the ethical issue at hand as well as to report the case to the Ethics Committee of the facility which would mean that she reports as a third party and with significant level of anonymity. This case scenario for Dr. TH is a perfect indication of the role that NPs should play in the upcoding while thinking about the ethical principles of care that outweigh the simple monetary gains (Lorenz, 2013).
As an NP, in such a collaborative setting, it would have been important to report the issue to the State Medical Society as a third party to avoid the fraudulent actions. This is considering that being part of the team, one may not be willing to risk their job and approach the ethics committee for the facility due to apparent familiarity shared with this group (Long, 2015). In an independent setting, the NP has a role to put in place in-house policies that guide the upcoding techniques and methods adopted so as to ensure that they fall within the accepted procedures. The NP has to recognize any simple case of fraud detected by the patients can simply take away the reputation of their profession, their facility and lead to diminished trust between them and the ir clientele; the patients and the society around (Lorenz, 2013).
References
Grant-Kels, J. M., Kim, A., & Graff, J. (2016). Billing and up coding: What’sa doctor-patient to do?. International Journal of Women's Dermatology.
Long, S. (2015). CONTROLLING CONTRACTING FRAUD: THE FALSE CLAIMS ACT PLEADING STANDARD AND ITS IMPLICATIONS FOR FRAUD IN THE NEW HEALTH CARE SYSTEM. Public Contract Law Journal, 44(4), 777.
Lorenz, F. A. (2013). Healthcare fraud in the United States: assessing current policy and its role in fraud prevention (Doctoral dissertation, California State University, Northridge).
