Were the actions of the coder correct or incorrect

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Reference no: EM133474565

Assignment:

For the past ten years, Juan Garcia has worked as the office manager for Dr. Smith, a local and well-respected osteopath in the community. It was brought to Mr. Garcia's attention by one of the coders that Dr. Smith appears to be upcoding some services for TRICARE patients. Mr. Garcia thought this was impossible as Dr. Smith has a high level of integrity and a position of authority in the community. The coder has four years of coding experience, is new to the office, and is unfamiliar with Dr. Smith's billing practices. Mr. Garcia is not a coder but understands the coding process required for TRICARE. When the coder brought this matter to Mr. Garcia's attention, the decision was made to hire an outside auditor to review Dr. Smith's submitted codes.

Six months later, Mr. Garcia had not yet arranged to hire an outside auditor. Much to Mr. Garcia's surprise, the Defense Health Agency's 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 and moved to another state to start working at another office.

1. At what point did Mr. Garcia need to do something about the potential allegations against Dr. Smith?

2. Were the actions of the coder correct or incorrect?

3. What should have been done in this situation and why?

Reference no: EM133474565

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