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Case Study 8

The setting is a billing office where clerks work in close proximity to each other, so that each can easily see what the other is doing. A billing clerk notices that one of his fellow employees is changing or adding codes to requisitions he is processing.
He asks the employee about it and is given the explanation that because the computer requires something to be entered in the ICD code field and he only does this with non-Medicare patients, it doesn't matter. The employee further states that this gives him more time to call for codes for the Medicare patients. What should the clerk who witnessed this action do about this situation?
Correct Answer: He should talk to the supervisor about the problem.
Discussion: Every employee who becomes aware of a violation of the law or a compliance policy has a responsibility to take action, which includes reporting the problem to a supervisor or the compliance officer. It doesn't matter that these patients are not Medicare patients, the important thing is that the employee is violating a compliance policy. If this employee does not report the problem he is himself violating a compliance policy. If it is subsequently discovered that he knew and didn't report it, he could be terminated. The employee's addition of the codes could create a big problem for the healthcare facility if an audit occurs.