Pressure to upcode a claim and a request for records with an unpaid balance
You are three months into an associateship at a private practice where you are paid 35% of adjusted production against a quarterly target. On Friday the principal asks you to change the record of a 20-minute problem-focused examination you performed for a patient with a single sensitive tooth into a 'comprehensive examination with eight radiographs'. No radiographs were taken, and no periodontal chart was completed. He says this is 'how we keep the schedule viable' and that the insurer will not query it. The same afternoon the receptionist tells you that a former patient has asked for copies of his radiographs and clinical notes to take to a new dentist, and the practice manager says nothing should be released until an outstanding balance of 180 in fees is settled. You have not signed or submitted anything yet, and your associate contract is silent on record access.
1. Analyse the request to alter the record and describe what you would do, including how you would document it.
Read the worked answer
The core problem. Recording an examination and radiographs that did not take place is not a coding ambiguity; it is fabrication of a clinical record and a false claim to a third-party payer. It breaches veracity, violates the duty to keep accurate records, and exposes both the individual clinician and the practice to fraud investigation, clawback, and regulatory sanction. The fact that an insurer may not query it is irrelevant - detectability is not the test.
Whose record it is. The clinical entries you make are your professional record even where the physical record belongs to the practice. You are the clinician of record for that examination and you are accountable for what appears under your name.
What to do. Decline clearly and without ambiguity, in person, and do not sign or submit the altered claim. Write a factual contemporaneous note of the examination actually performed, in the record itself, at the time of the request - for example: 'Problem-focused examination of tooth X performed; no radiographs taken; no periodontal charting. Record amended at the request of [principal] to a comprehensive examination with eight radiographs, which was declined as inaccurate.' Keep that note factual and free of commentary about colleagues.
Follow-up. Raise the issue in writing, ask for the practice's written policy on record accuracy and claiming, and keep a personal copy of relevant correspondence. If the request is repeated, seek advice from your professional indemnity organisation or regulator before the situation escalates. Check the associate contract for any clause that attempts to make you liable for claims you did not authorise. The pattern matters more than the single incident: a one-off misunderstanding is different from a systematic instruction to inflate claims, and the latter may require a formal report.
2. How should the request for the former patient's records be handled, and does the unpaid balance change anything?
Read the worked answer
Ownership versus access. In most jurisdictions the physical record and radiographs belong to the practice or the clinician who created them, but the patient has a legal and ethical right to access their own clinical information, including copies and a summary. Ownership of the paper is not the same as control of the information. The patient should not be required to give a reason for the request, nor to authorise release to a named third party beyond confirming identity.
The balance is a separate matter. A debt owed to the practice is a commercial dispute; withholding clinical records to enforce payment is generally not permissible, may breach data-protection or health-records legislation, and in many jurisdictions is expressly prohibited. The two issues should be handled in parallel: release the records while pursuing the debt through ordinary invoicing and, if necessary, a civil process. Where local law does permit a fee, it is usually limited to the reasonable cost of copying and postage, not to the outstanding clinical debt.
Practical steps. Confirm the patient's identity and the scope of the request in writing; provide radiographs and notes as copies, keeping the originals; include a factual summary where the notes are cryptic; respond within the statutory timeframe (commonly 30 days, or one month under many data-protection regimes - check your jurisdiction); and record what was sent, to whom and when. Alert the principal in writing that the records were released and why, so that the practice manager's instruction is not later portrayed as having been followed. If the practice insists on withholding, escalate to your indemnity organisation; do not refuse the patient unilaterally without advice.
3. If the pressure continues, what practical and professional steps would you take, and how would you protect yourself if you left the practice?
Read the worked answer
Escalation ladder. First, a written, factual request to the principal to confirm in writing the practice's record-keeping and claiming policy. Second, advice from your professional indemnity organisation and, if the conduct appears systemic, from the relevant regulator or a fraud-reporting channel; this can often be done confidentially while you remain employed. Third, if instructed in writing to falsify a record, refuse in writing and keep a copy off the premises.
Protecting yourself. Keep personal copies of your own clinical records or a log of what you did, in line with local data-protection rules and your contract - do not copy patient-identifiable material indiscriminately. Retain correspondence, rotas and pay statements that show you were not the author of disputed claims. Check whether the contract contains a restrictive covenant, notice period and any clause making you responsible for claim adjustments; if it does, take legal advice before resigning. Ensure your own registration, indemnity cover and CPD are independent of the practice.
Leaving. Resign in accordance with the notice period, in writing and without allegations you cannot substantiate. Hand over ongoing patient care properly - outstanding treatment, referrals, laboratory work and records - because abandoning patients creates a separate professional problem. Provide a factual exit statement if asked, and cooperate with any subsequent investigation rather than relying on the passage of time.
Underlying principle. The associate's production-based pay and the quarterly target create a conflict of interest; the defence is transparency - accurate records, contemporaneous notes and written communication - not accommodation.