You’re responsible for submitting a risk diagnosis to CMS for payment purposes. You use a specific process to verify the data is accurate. Your immediate supervisor tells you to ignore the process and adjust or add risk diagnosis codes for certain individuals. What should you do?
A. Do what your immediate supervisor asked and adjust or add risk diagnosis codes
B. Report the incident to your compliance department (via compliance hotline or other mechanism)
C. Discuss your concerns with your immediate supervisor
D. Call law enforcement
The Correct Answer and Explanation is:
Correct Answer: B. Report the incident to your compliance department (via compliance hotline or other mechanism).
Explanation
In the healthcare industry, submitting accurate risk diagnosis data to the Centers for Medicare & Medicaid Services (CMS) is both a regulatory and ethical obligation. This data directly impacts payments and government reimbursements. Falsifying or inflating diagnosis codes to increase payments can constitute fraud under the False Claims Act and other federal statutes.
In the scenario described, your supervisor’s instruction to “ignore the process” and manipulate coding—especially if it’s to intentionally inflate or falsify risk scores—crosses legal and ethical boundaries. Following such an instruction would make you complicit in potential fraud, exposing both yourself and your organization to serious legal consequences including fines, criminal charges, and reputational damage.
While it might be tempting to follow your supervisor’s directive due to power dynamics or fear of retaliation, you have a professional and legal duty to uphold integrity in healthcare documentation. Internal compliance programs exist precisely to protect employees, patients, and organizations from unethical practices. Most healthcare organizations provide anonymous compliance hotlines or other reporting mechanisms to handle these concerns discreetly and effectively.
Although Option C (discussing your concerns with your supervisor) might seem reasonable, it is insufficient if the supervisor has already made their intentions clear. Internal reporting to the compliance department (Option B) is the appropriate action, as it ensures the concern is documented and addressed at the proper level, potentially triggering an internal investigation.
Calling law enforcement (Option D) is not the correct first step; internal mechanisms should be used first unless there’s an imminent danger or ongoing criminal activity that is not being addressed.
Therefore, Option B is the best choice: it aligns with compliance protocols, protects patients and public funds, and fulfills your duty as a healthcare professional.
