Opinion ID: 172871
Heading Depth: 3
Heading Rank: 3

Heading: Billing Fraud Investigation

Text: On September 30, 2003, around the time the ad hoc committee had completed its investigation of the disruptive conduct complaint, Patsy Carter, suspecting that Dr. Couch might have billed for services he did not perform, sent the records of three patients [9] to the Mountain-Pacific Quality Health Foundation (MPQHF) for evaluation of whether Dr. Couch committed Medicare or billing fraud. [10] MPQHF's report confirmed the hospital's suspicions, and indicated that both of MPQHF's peer reviewers concluded that Dr. Couch apparently was billing for services that were not performed. The report recommended that Dr. Couch receive thirty hours of training in charting in the next six months, be suspended from call rotation for six months, and be required to dictate all his charts within twenty-four hours of providing patient services. Further, the report recommended that Dr. Couch be reported to the Wyoming Board of Medicine and to the National Practitioner Data Bank for his careless actions. (Aplt. App. 1032.) As per MPQHF's recommendations, Ms. Carter forwarded MPQHF's report to the WBM. [11] Based on the results of the MPQHF report, the Credentials Committee, on March 2, 2004, informed Dr. Couch that he was required to obtain 30 hours of training on proper coding and physician responsibility for coding in a formal setting within the next 6 months. (Aplt. App. 1372.) In an apparent effort to get that training, Dr. Couch subsequently attended a practice management course; however, the Credential Committee determined that the course did not fulfill the proper course training requirements. (Id.) This matter was then forwarded to the Executive Committee, which voted, on January 20, 2005, to reduce [Dr. Couch's] clinical privileges in that he will be suspended from call rotation for unassigned patients until he attends a total of 30 hours of training in proper coding and physician responsibility in coding. (Id. at 700.)