The District Manager's Billing Instructions and a Records Request Gone Wrong
Dr. Cho is the only optometrist in a five-location optical chain. Her district manager emails instructions to add the diagnosis "glaucoma suspect" to every patient over 50 whose screening intraocular pressure reads 22 mmHg or higher, and to bill each diabetic patient's annual visit as a 99214 medical office visit plus a 92014 eye exam on the same day, whether or not a systemic problem was addressed. When Dr. Cho objects, the manager says "the doctors in Florida do it this way" and mentions her productivity ranking. Separately, a former patient asks for a copy of her complete record. The front desk tells her the practice releases records only to other physicians, quotes a $95 copy fee, and says it will take eight weeks. The patient says she is moving the record to a new optometrist next week and mentions that she may file a complaint.
1. Analyze the manager's diagnosis and billing instructions under Michigan law and describe Dr. Cho's exposure if she complies.
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Two separate violations are being requested.
The upcoded medical visits. Billing a 99214 plus a 92014 for every diabetic patient regardless of what was done is a coding misrepresentation. Medical decision-making level must be supported by the documented history, examination, and complexity; a routine annual diabetic eye examination with no systemic problem addressed does not generate a 99214 no matter what the schedule says. Add the duplicate same-day exam code where no separate service was rendered and the pattern is not a documentation weakness, it is a scheme.
The invented diagnosis. Appending "glaucoma suspect" to every patient over 50 with a screening IOP of 22 or higher is fabricating a diagnosis to justify payment. A screening tonometry reading is not a diagnosis; a glaucoma suspect designation requires optic nerve evaluation, risk assessment, and clinical judgment, and the record must show it.
Exposure if she complies. Falsifying a diagnosis and submitting claims on it are grounds under MCL 333.16221 for fraud or deceit and for violations of the article, and they are independent insurance-fraud and false-claims exposure that no employment relationship insulates her from. "My manager told me to" has never been a defense for the licensee whose signature is on the claim, and the board will note that she is the only optometrist in the chain, which makes her the responsible clinician.
The correct response is documented refusal in writing, escalation past the district manager to compliance and legal, a request for a coding audit of existing claims, and repayment of anything already billed incorrectly. If the instruction persists, she should consider whether continuing to practice in that structure is sustainable, because the next audit will name her.
2. What must the practice do about the records request: who is entitled to a copy, in what form, on what timeline, and at what cost?
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Michigan's Medical Records Access Act governs this, and the front desk has answered wrong on all three counts.
Who. The patient is entitled to her own record. A blanket "we release only to physicians" policy has no basis in the Act; the patient or her authorized representative may obtain a copy, and a written authorization permits release to a third party. The practice may not condition release on the new provider making the request.
What and how. The record means the information the practice maintains, including examination findings, images and their interpretations, prescriptions, and correspondence. Where the request is for a copy, the practice must provide it in the form requested where feasible, or as otherwise permitted by the Act. Refusing to release until a balance is paid is not a general entitlement; there are only narrow statutory grounds for delay or denial, and an unpaid bill is not a free pass.
Timeline. The Act sets a deadline measured in days from the request, on the order of 30 days, and permits one extension in defined circumstances with written notice. Eight weeks with no written response is a violation.
Cost. The Act caps charges for copying at a schedule that includes an initiation fee and per-page amounts, with different treatment for records already prepared or provided in another medium. A flat $95 charge for a routine chart will almost certainly exceed the cap. The practice should publish its fee schedule, itemize the charge, and be prepared to justify each line.
Because the patient has signaled a complaint, the practice should respond in writing within the statutory window, produce the record, charge only what the statute permits, and keep a copy of the correspondence.
3. Describe what happens if the patient or a payer files a complaint, from intake to final order, and where Dr. Cho's cooperation fits.
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Intake and investigation. A complaint to LARA's Bureau of Professional Licensing is screened and, if it alleges a licensing violation, assigned to an investigator. The investigator may request patient records, interview staff, and subpoena documents. This is the stage where a licensee's cooperation is weighed most heavily; refusal to respond or record alterations at this point become allegations of their own.
Administrative complaint. If the investigation supports a violation, the department serves an administrative complaint setting out the allegations and the statutes and rules involved. The licensee files a response within the deadline.
Alternatives. Minor, clearly defined matters may be resolved through a compliance conference or an administrative consent order rather than a hearing. That option narrows once the allegations include fraud or fabricating diagnoses.
Hearing. Contested cases go before an administrative law judge in the state's administrative hearings office. Both sides present evidence and testimony; the standard is preponderance of the evidence.
Proposal for decision. The ALJ issues a proposal for decision with findings and recommended sanctions.
Board and director. The Board of Optometry's disciplinary subcommittee reviews the proposal and recommends sanctions, and the director of the department issues the final order. Sanctions available under MCL 333.16226 include reprimand, probation with conditions, practice limitations, fines, suspension, or revocation, plus costs and CE conditions. Where immediate public harm is threatened, summary action can precede the full process.
Appeal. Review is by the circuit court on the administrative record.
For Dr. Cho, the practical point is that her position is strongest if the file shows contemporaneous written objection to the instructions, a request for a compliance review, and honest records. That is what separates her from the manager who gave the order.