Discussion Board Prompt:
For the past 10 years, Juan Garcia has worked as the office manager for Dr. Smith, a local and well-respected osteopath in his community. It was brought to Mr. Garcias attention by one of his coders that Dr. Smith appears to be upcoding with some of his services for TRICARE patients. Mr. Garcia thought this was impossible as Dr. Smith had a high level of integrity and position of authority in the community. The coder has four years of coding experience, and she is new to the office and not familiar with Dr. Smiths billing practices. Mr. Garcia is not a coder, but he understands the coding process required for TRICARE. When his coder brought this to his attention, he decided to have an outside auditor review Dr. Smiths submitted codes.
Six months later, Mr. Garcia had not yet arranged to hire an outside auditor. Much to his surprise, the Office of Inspector General (OIG) arrived at the practice and removed everything from the premisesrecords, computers, and anything that might prove TRICARE or other payer billing fraud. The next week, the coder resigned from her position and moved to another state to start working at another office.
At what point did Mr. Garcia need to do something about the potential allegations against Dr. Smith?
Were the actions of the coder correct or incorrect?
What would you have done in this situation?
Must be at least 250 words with two cited sources in APA format
Will included textbook information below:
Textbook information
Green, Michelle A. Understanding Health Insurance: A Guide to Billing and Reimbursement,
2021 edition with MindTap Access. Cengage Learning. 2022. ISBN-13: 978-0-357-51562-4
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