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Coding Error in Orthopedics – Mini Case Study

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Coding Error in Orthopedics – Mini Case Study

1. What documents would you bring to your meeting with the medical director?

The planned meeting with the medical director defines the first step towards fighting

and eradicating fraud in the workplace. Professionals in the healthcare sector play a vital role

in protecting the integrity of the programs that help individuals access and pay for healthcare

services, and it is imperative that everyone participates in protecting their workplace from

engaging in violations and abusive practices. Medicare fraud, such as the one depicted in the

case study, describes knowingly submitting, or causing to be submitted, false claims to obtain

a Federal health care payment (Herland et al., 2018). The current case features

misrepresentations of facts with which the practice makes false claims for Federal payments.

The documents to bring to the meeting should expose the identified violations and

abusive practices by the organization's CEO. According to the case study, confusion emerged

when attempting to match each patient's medical records with their claims and

reimbursements. The orthopedic group practice has been upcoding its services to fraudulently

inflate its reimbursements. In this regard, the documents to bring to the meeting should

include evidence of coding error, which require a document of the proper medical coding

classification such as the ICD-11. Another document should be evidence of a mismatch

between the patient's medical records and their claims/reimbursements.

2. What professional standards has the CEO violated?

By engaging in the portrayed fraudulent activities, the CEO violated a vast array of

professional standards in healthcare. Healthcare executives must personally demonstrate their

commitment to the healthcare profession by observing integrity, honesty and trust. According

to the American College of Healthcare Executives (ACHE) (2022), healthcare executives

must affirm their personal responsibilities to the profession, organization, and organization.
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In this aspect, they are expected to build a culture of trust, collaboration, and respect not only

within the organization but also with other organizations. Healthcare executives are

responsible for ensuring that they refrain from participating in abusive activities that demean

not only the credibility but also dignity of the healthcare profession and its leadership

(ACHE, 2022). Moreover, they have a responsibility to the organization, which includes

preventing fraud and abusive/aggressive accounting practices that may result in inaccurate or

disputable financial reports (ACHE, 2022). In the current case, the CEO is dishonest,

untrustworthy, and lacks integrity. The CEO is knowingly falsifying facts and

misrepresenting information to fraudulently claim undeservingly higher reimbursements. As

a result, the CEO has violated the healthcare executive’s responsibility to refrain from

participating in activities that demean the profession and perpetuate fraud. Also, Cellucci et

al. (2022) explain that professionals should maintain professional values, which include self-

regulation, public service, and refraining from actions that demean the profession. The CEO's

willful engagement in fraud violates all these professional values.

3. Is it likely that the CEO is licensed?

It is very likely that the CEO is not a licensed healthcare professional. As a hospital

executive, like many other positions of hospital administrators, the CEO manages and

oversees the operations of the orthopedic group practice. In light of this noble responsibility,

the CEO is ultimately responsible for the safety, health, and care of all the patients, as well as

the subordinates' well-being. As an administrator, the CEO may have had two possible career

paths. The CEO may have started as a registered and licensed healthcare practitioner, an

orthopedic for example, and worked her way up to the top executive position. Like many

firms in other sectors and industries, healthcare organizations tend to have career

development and growth programs with which their employees growth and develop their

skills and knowledge toward higher career stages. In this case, the CEO may have climbed up
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from a licensed entry-level practitioner to a top administrator in the organization. The other

alternative may have been securing the top executive position based on academic and

professional credentials – healthcare leadership credentials. Besides, there are no formal

licensing requirements for healthcare administrators in the United States (US). However,

based on the CEO's willful violations and abusive activities, it is very likely that he/she is not

a licensed healthcare professional; otherwise, he/she would not have violated the core

principles of the healthcare profession.

4. Which credentials - academic and professional - could the CEO hold?

The CEO, like any other top administrator in the healthcare sector, must have the

required level of skills and knowledge. To qualify for the executive role, the CEO must have

a minimum of a Bachelor's degree. However, the CEO position in hospitals and other

healthcare facilities requires at least a Master's degree, which must typically relate to

healthcare and its related administrative fields. Apart from the academic aspects of the

requirements for the top administrative position in healthcare, the CEO could also be holding

years of experience in management positions, which may be in finance management, human

resources, and even COO before her appointment to the CEO position.

5. Would you immediately report the CEO to her association's professional standards

committee (or a similar entity that investigates violations of professional standards)?

Yes, I would immediately report the CEO to her association’s professional standards

committee, or a similar entity that investigates violations of professional standards. Every

employee, including healthcare executives, is responsible for reporting violations of the Code

of Ethics and professional standards. Some cases of suspected fraudulent activities may

constitute honest mistakes or unintentional errors thus, it is imperative to check with the CEO

first before further action. However, in the current case, the CEO acknowledged her
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awareness of upcoding their services for higher reimbursements and claims, which constitute

willful fraudulent practices. Therefore, I would execute my duty to communicate such facts

to the responsible body for further action.

6. What laws have been broken? Who should be held responsible?

The case study features violations of the Federal Civil False Claims Act (FCA). The

Act was enacted to protect the government from being sold substandard goods or services, or

being overcharged. It imposes civil liability upon individuals and organizations who

knowingly submit, or cause submission, of fraudulent claims to the Federal Government.

Therefore, if the individual's choices are deliberately ignorant or recklessly disregard the truth

and submit or cause the submission of false information with which to exploit the

government, then it is a violation of the FCA. In this case, the CEO and her accountants are

liable for the violations. The accountants have willfully falsified information, upcoding the

services, to claim more than the required reimbursements. The CEO, in this case, has

deliberately caused the false claim by enabling the upcoding of services in the organization.

Therefore, the current case depicts Medicare violations of FCA by the CEO and her

accounting team, and they are subject to possible criminal penalties under 18 U.S.C. Section

287.

7. Should you find another job?

Yes, I believe that finding another job would be the best course of action under the

current circumstances. The CEO is running a fraudulent workplace that goes against all of the

core professional and personal principles that guide my desire to work and develop my

career. Also, there have been numerous cases in which workplace leaders take retributory

actions against whistleblowers, even though there are laws for protection in such instances. In

this regard, just by reporting the CEO's violations and abusive practices, and finding another
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job would be the most appropriate action to avoid working in a hostile work environment.

Therefore, I would find another job.

References

American College of Healthcare Executives. (2022). Code of Ethics.

https://www.ache.org/about-ache/our-story/our-commitments/ethics/ache-code-of-

ethics

Cellucci, L. W., Cellucci, T., Farnsworth, T. J. (2022). Ethics and professionalism for

healthcare managers (2nd Ed.). Health Administration Press.

Herland, M., Bauder, R. A., & Khoshgoftaar, T. M. (2020). Approaches for identifying US

Medicare fraud in provider claims data. Health Care Management Science, 23(1), 2-

19.