A solo-practice provider has been practicing in a specific area for 19 years. At 20 years, the staff, several of whom have been with the doctor since the start, can collect retirement through a contracted vendor. However, due to a diminishing of insurance reimbursement, the doctor cannot keep the doors open any longer. The provider realizes that both her and her employees are unlikely to find employment that will provide for any means of financial security in their aging years. Attempts at marketing and attracting additional clients have been unsuccessful as a result of managed care contracts and preferred provider arrangements that have gone to hospital-based physicians. There are no other options, save one. The provider knows that if she upcodes the visits and charges more, she can keep her doors open and retire in a short 12 months.
In your main discussion post, discuss the current dilemma from the perspective of the provider and from the perspective of the staff. Are there any gray areas to this dilemma? If so, can you understand why a provider would be tempted to upcode? Unfortunately, this dilemma is happening across America. In replying to your peers, evaluate their positions on this dilemma. Did you find common ground?
REPLY TO MY CLASSMATE’S DISCUSSION TO THE ABOVE QUESTION AND EXPLAIN WHY YOU AGREE. (MINIMUM OF 200 WORDS)
CLASSMATE’S POST
The provider’s dilemma is that her practice is no longer successful and on the verge of closing its doors after 19 years. Not only does she only have 1 more year before retirement, but her loyal office staff is also on the verge of being unemployed. Since the physician and her staff are older, the physician fears that they may not receive any employment. For the staff, since they have been long term employees, they are loyal and trust the physician with her decisions.
The temptation to keep the business running and successful is apparent. One illegal choice to keep the practice going is by upcoding and overcharging insurance companies for services not performed. Since no physical harm may come to the patient by upcoding, it is still illegal. However, a physician has a moral and legal obligation to “do no harm.” This is in relation to their patient care aspect but also their practice and employees. The physician has legal and ethical values to uphold. “A number of characteristics are associated with medical ethics such as autonomy, confidentiality, nonmaleficence, beneficence, honesty, justice, and dignity. Medical professionals’ decisions are based not only on clinical and technical grounds but also on ethical grounds (Kumar et al. 2019, p112).” There is no gray area in this situation, either the physician has intent to perform upcoding or she decides not to.
Since she is a loyal physician to the community and as a healthcare professional, I do not see how someone could do such intentional harm. She could have the potential to get caught, jeopardize her medical license, must repay damages and fines, and could potentially get her staff in legal trouble. It is unfortunate that this action of malicious and misconduct occurs. It has been found that “more urbanized states and states with a larger elderly population experienced a greater incidence of medical fraud (Goel, 2020, p520).” In 2019, a healthcare company, Sutter Health were accused of upcoding and agreed to settle and pay $30 million (Modern Healthcare, 2019). Healthcare costs for services are increasing but performing illegal actions to keep your business running is ethically wrong.
References
Goel, R. K. (2020). Medical professionals and health care fraud: Do they aid or check abuse? Managerial & Decision Economics, 41(4), 520–528. https://doi.org/10.1002/mde.3117
Kumar, L., Barwa, J., Sharma, J. P., Ohri, P., & Beg, M. A. (2019). Developing a Module of Medical Ethics for Post MBBS. Journal of Punjab Academy of Forensic Medicine & Toxicology, 19(2), 112–119. https://doi.org/10.5958/0974-083X.2020.00021.7 Sutter Health will pay $30M to settle upcoding allegations. (2019). Modern Healthcare, 49(15), 2.
