consider that you are the assistant manager of operations for the Smith Home Health Care Services. Part of your job is to do impromptu visits where internal audits are completed as a measure to monitor the home health nurses and aides for the company.

These responses are based on these set of questions and each response must be answered in 100 or more words in APA format.

 

Falsification of records and billing are serious offenses and must be treated as such. As a health administrator, you will be called upon to monitor staff to be sure that records and billing are accurate.

In this scenario, consider that you are the assistant manager of operations for the Smith Home Health Care Services. Part of your job is to do impromptu visits where internal audits are completed as a measure to monitor the home health nurses and aides for the company.

You have been observing Barbara Smithers, who has been a home health aide since the company was established in 1995. You notice, before one of your monitoring visits, that Barbara’s billing totals seem higher than the average worker. When you observe her home services and compare them to the services rendered, there is a discrepancy. Going back in her service records, this has been a pattern for at least 4 years. You report this to your supervisor, Ron James. Mr. James meets with Barbara, who finally admits that she has been “padding” the billing for at least 10 years, at the demand of nursing supervisor, Donna Strickland. Mr. James asks you to sit in on a conference with Ms. Strickland and Ms. Smithers and contribute to questioning them and helping make a final decision.

  • If accusations turn out to be true, what would be your recommendation in this case be to the Mr. James? What records do you need to review before the conference? Be sure to cite standards from the False Claims Act.
  • How did the Service fail in its responsibility in monitoring Barbara? Should the facility also be held responsible?
  • Could the Service have avoided this situation? Does 4 years of potential fraudulent billing seem a reasonable time period for no one to notice?
  • What are the consequences of this behavior? Is there a criminal case here? What about civil liability? Are there any non-monetary consequences this Service should now be worried about?

First response:

I am the assistant manager of operations for the Smith Home Health Care Services. I have been observing Barbara, who has been a home health aide since the company was established in 1995. I have noticed, before one of my monitoring visits, that Barbara’s billing totals sum higher the average worker. When I observed her home services and compare them to the services rendered, there was a discrepancy. Looking back in her service records, this has been a pattern for at least 4 years. I reported this to my supervisor, Ron James. Mr. James meets with Barbara, who finally admits that she has been “padding” the billing for at least 10 years, at the demand of nursing supervisor, Donna Strickland. Mr. James asks me to sit in on a conference with Ms. Strickland and Ms. Smithers and contribute to questioning them and helping make a final decision.

If the accusations turn out to be true, what would be my recommendations in this case in reference to Mr. James? What records do you need to review before the conference? When Mr. James questions Barbara, Barbara admits she has been “padding” the billing for at least 10 years, so at this point we can say that the accusation is true and that the act was willing. My recommendations to Mr. James would be to start a plan of correction and audit all of the billing claims in the organization for accuracy and set a monitoring system to make sure that the fraudulent behavior does not happen again. In addition, termination of employee and taking out criminal charges. Before the conference a thorough investigation of the claims records would need to be reviewed from the past 10 years. Barbara has now subjected the organization and herself to the False Claims Act which states:

  • “Knowingly presents, or causes to be presented, to an officer or employee of the United States a false or fraudulent claim for payment or approval”;
  • “Knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claim paid or approved by the Government”;
  • “Conspires to defraud the Government by getting a false or fraudulent claim allowed or paid (Showalter, 2012, p. 437).

How did the service fail in its responsibility in monitoring Barbara? Should the facility be held responsible? Well, in the scenario it states that Barbara has had a pattern for at least 4 years and Barbara states she has been “padding” for the past 10 years. So, this just tell us that there was indeed a system failure and that claim records were not being monitored on a consistent basis to assure accuracy? Yes, the facility should be held responsible. It is the responsibility of the healthcare administrator to make sure that mechanisms such as corporate compliance programs put in place to verify accuracy of their organization’s claims. According to Showalter (2012), this standard requires healthcare providers, and their tip management and governing board members, to have mechanisms in place to verify the accuracy of their organization’s claims. When a healthcare provider fail in its responsibility in monitoring its claims the organization will come into the subjection of the False Claims Act.

 

Could the service have avoided this situation? Does 4 years of potential fraudulent billing seem a reasonable time period for no one to notice? Yes this situation could have been avoided. This was definitely a system breakdown. It is the responsibility of the healthcare administrator to make sure that mechanisms such as corporate compliance programs put in place to verify accuracy of their organization’s claims. No, 4 years of potential fraudulent billing does not seem to be a reasonable time period for no one to notice. According to Showalter (2012), this standard requires healthcare providers, and their top management and governing board members, to have mechanisms in place to verify the accuracy of their organization’s claims.

What are the consequences of the behavior?

  • False Claims Act (FCA) violations range from $5,500 to $11,000 per claim
  • Civil penalties
  • Criminal convictions
  • Loss of participation in Medicare and Medicaid

The threat and the potential for criminal convictions and massive fines have been the major forces motivating healthcare organizations to adopt corporate compliance programs (Showalter, 2012, p. 439).

Is there a criminal case here? What about civil liability? Are there any non-monetary consequences this Service should now be worried about? Yes, there is a criminal case and a civil liability. Yes, there are non-monetary consequences this Service should now be worried. One non-monetary consequence the Service should be worried about is their reputation that is now under scrutiny and at stake in the community.

 

Reference:

Showalter, J. S. (2012). The Law of Healthcare Administration. (6th ed.). Chicago, IL: Health Administration Press.

Second response:

Falsification of records and billing are serious offenses under the law. For these reason, as a health administrator, I will supervise and monitor staff to make sure that each employee is following procedure; but in this case I will implement an emergency meeting with the upper level executive CEO, all supervisor/ managers, a lawyer/consultant, financial management coordinator, Donna S. Ms. Strickland, Ms. Smithers, Mr. James, and Barbara, who admits that she has been padding the billing for ten years. In the meeting I will discuss and review policies, evaluations, supervision notes, trainings, credentials/education, claims, financial statements/ records, and be able to clarify the protocols/professional ethic.  After everything is review I will pursue with the federal law.  As a health administrator I will never wait to report a fraud, because then I will be involve in this fraudulent conduct. According with Showalter, (2012),  “Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties”(p. 441).   Subsequently, staff is expected to follow healthcare organization financial rules and information management policies regarding medical records which each employee is responsible for their job. Showalter report that, “Federal law makes filing false claims a criminal offense. An organization may be fined $500,000 or twice the amount of the false claims whichever is greater. An individual may be fined the greater of $250,000 or twice the amount of the false claim and may be five years of prison” (John R. Showarlter, 2012, p. 441)

Anti-Fraud campaign article by Lisa explain explained that, “Frauds costs the US. Healthcare system some $65 billion a year from Medicare alone, and the affordable Care Act (ACA) give the government greater authority to identify and prosecute fraud and abuse.  Especially considering the most recent federal task force bust that tallied $430 million in false billing claim and levied charges against 100 individuals including physicians” (Zamosky, 2012).  As a consequence, ACE create a new strategy plan, implementing educational training for staff, strategies to resolve a billing errors, building a compliance plan, conduct your own audits, increase new technology, controlling the HER, and dealing with an audit.

In conclusion, I believe that staff must be educated, to be honest, make sure they understand policies, financial statements, and follows the law. Managers and supervisor must to be aware of any issues, implementing schedules for supervision, meetings, measure performance evaluation/ feedbacks, provide training according with the organization goals, hire lawyer or consultant, an accountant, to review audits/financial records, and policies. As a result, to avoid any other fraud.

Reference

John R. Showarlter, J. M. (2012). The law of Healthcare Administration . Washington DC.

Zamosky, L. (2012, December). Anti-Faud campaing could trigger wave of audits, experts warn. Retrieved from http://www.baltimoresun.com/news/opinion/oped/bs-ed-obamacare-20131021-story.html.

“Get 15% discount on your first 3 orders with us”
Use the following coupon
FIRST15

Order Now