Question

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. Garcia’s 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. Smith’s 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. Smith’s 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 premises—records, 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.

What would you have done in this situation?

Answer 1

submit a fraud report online and inform the nearby state to check for his coding certificates.Please include only the necessary contact information and brief details about the suspected fraud when making submissions. Do not include sensitive data such as Personally Identifiable Information (PII) or Personal Health Information (PHI). Should PII or PHI sensitive information be required DHA-PI or our contractor will advise you regarding the needed information and request you provide that information by mail or fax. Precautions must be taken by Government agencies to avoid violating DoD policy, the Privacy Act, and/or HIPAA.