Stephanie went to work in the billing office of a physician who had emigrated from another country – one in which women’s rights are not valued in the same way they are in the US and where bribery is a common practice. The physician was very clear with Stephanie that it was her responsibility to obtain as much revenue as possible and the “playing with the rules” was not only acceptable, but also encouraged.

Stephanie was highly uncomfortable with this situation – it went so far that she became aware that the physician was submitting charges for services that he never provided. She attempted to speak with the physician about her concerns, but he exploded into a rage, stating “How dare you questions me! Don’t ever talk to me about this again or you are fired.”

1.     How should Stephanie respond in this situation?

2.     If the physician was asked about his behavior, he would indicate that he did absolutely nothing wrong- his behavior is consistent with his societal ethical norms. Explain how you would tell him that his standards are wrong?

The patient seeks a high-dollar medical service that is often not covered by his insurer. According to practice guidelines, the provider’s representative calls the insurer to confirm benefits and is told that diagnosis of the patient’s condition is covered but treatment is not.

            As a result, the provider’s representative asks the patient to pay the balance for treatment before service begins. The patient asks the provider to code the treatment services as diagnostic services (using symptom codes). The provider, who has gone through this scenario before, absolutely refuses to mischaracterize the diagnosis codes.

            The patient has a flexible spending account (FSA) that will reimburse him for services not covered by insurance. However, to obtain that FSA payment a denial must be received from the insurer. The physician’s office submits the claims to get the denial for the patient, but the insurer unexpectedly pays for the services. Two days before the provider actually receiv3es the funds, it receives a phone call from the patient, who received an explanation of benefits (EOB) from the insurer. The patient wants to receive a refund of the money that he paid since the insurer “covered” this service. The patient insists that if he does not receive the refund immediately, he is going to call his attorney.

1.     At this point, have any ethical dilemmas occurred?

2.     Is it an ethical problem for the provider’s office to comply with the patient’s request? Why or why not?

3.     Do the circumstances change if the provider calls the insurer and the insurer’s representative insists that the claim payment is correct? Does this solve the problem? Are more ethical problems created? Explain.