Posted: March 20th, 2017

HA525 Unit5 discussion

 
In 200 words or more, create a post that fully
addresses the following.

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

In two different paragraph with no less than 100 pages give your personal opinion to   Brenda Newcomb  and Marivette Bedoya

 Marivette Bedoya 
Healthcare fraud is a crime that has effects on everyone and should concern government officials, taxpayers, insures and premium payers, healthcare providers and patients. This is overall, costly. We all would like to believe that the employees are loyal and working for the benefit of the organization, however, there are many ways in which fraud can be committed. If the accusations turned out to be true, recommendations that I would give to Mr. James would be to perform above and beyond necessary research to insure all information and facts have been gathered and identified. Prior to the conference with Ms. Strickland and Ms. Smithers, records would need to be reviewed that include: previous timesheets and billing statements. It is important for us to review those documents to determine the amount of hours that were worked, compared to what the individual should work and how much each client was billed for services over the past 10 years. We would also need to review the actual services rendered compared tp what the clients were charged for. The service failed in its responsibility to monitor Barbara because its administrators had not been vigilant in ensuring that important visits and internal audits were being carried out on a consistent basis. This was evidence by the fact that Barbra had been “padding: the billing for the past 10 year with one one noticing it. Because of this, I believe that the government should hold the facility responsible. I believe that the Service could have avoided this situation if every staff member was given notice of new polices and protocols. The 4 years of potential fraudulent billing is not too long of a time period for no one to notice. All consequences include civil penalties, loss of participation in both Medicare and Medicare, criminal convictions. Also, the accused may be fined per claim according the the False Claim Act, ranging from $5,500 to $11,000. There is a criminal case as well as civil liability. There are non-monetary consequences and the Service should be worried (Showalter, 2017). The worry should be in regard to their reputation being at risk. 
References: 
Showalter, J. S. (2017). The Law of Healthcare Administration (8th ed.). Chicago, IL: Health Administration Press.

 
 Brenda Newcomb 
I would remind Mr. James, that they both violented the false claims act, that caused fraudulent billing, in the way, that one provided the remuneration and the other one received it. My recommendation for Mr. James would be to suspend both employees immediately, until an investigation was done, then terminate them upon guiltiness. I would then suggest calling the police and reporting them. I would also recommend that both should be excluded from participating in the Medicare and Medicaid programs. Before the conference, I would review the home service records and billing records (Showalter, 2017).
“The standards of the false claims act includes the following:  

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.
Knowingly makes, uses, or causes to be made or used, a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the government” (Showalter, 2017).

The service failed in its responsibility in monitoring Barbara by not following the corporate compliance programs. When having an ineffective corporate compliance program carries the consequences of ethical and illegal activities occurring in the company. The facility should be held responsible for the fraudulent billing activity of both women because it has gone on for 10 years. I think the home service could have avoided the situation if all employees were given notices of new policies and they were acknowledged and understood the rules of the law. I also think if the meeting were done on the corporate compliance programs, then it may have avoided the fraudulent billing from the two employees.  I think that 4 years is too long not to notice that fraudulent activity was going on. I think 6 months to a year would be of potential fraudulent billing is a reasonable time period for no one to notice (Showalter, 2017).
The consequences of fraudulent behavior are criminal convictions and financial penalties. In this case, there is a criminal case involving both employees because they violated the false claims act. There is also a violation of corporate compliance programs concerning the company. Civil liability, in this case, relies on the nursing supervisor, Donna Strickland, who is responsible for damage to Barbara because she demanded Barbara in doing the illegal acts. The service should be worried about the non-monetary costs of the company (Showalter, 2017).
Showalter, J. S. (2017). The Law of Healthcare Administration (8th ed.). Chicago, IL: Health Administration Press.

 

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