Question

Who You Gonna Call?—Case for Chapter 16

Kevin D. Zeiler

Working in the billing department for a large, for-profit health care organization has been a dream come true for Nicki Knowitall and she is excited about her future opportunities. Nicki has been with the company for two and a half years and was just promoted to senior Medicare Billing Specialist. Since Nicki has been dealing with Medicare for over two years, she jumps right in and continues with the same billing practices she has been using and trains her staff with these techniques.

Because Nicki’s new position allows her to view information that she was not previously privy to, she has started to notice some discrepancies surrounding the way many of the Medicare invoices are coded. She pulls several of these invoices and shows them to her supervisor. The supervisor informs her that this is how they will continue to code these documents and that Ms. Knowitall should focus solely on training and monitoring her staff. Nicki finds the response she received to be very strange, but nevertheless, she goes back to her work.

Six months pass and Nicki has grown more distraught as she has collected literally thousands of invoices that are coded incorrectly, but there is nothing she can do to change them at her level. She does not feel comfortable approaching her supervisor again, and she is concerned that going higher up the chain of command may make it even worse. To compound the problem, Nicki reads in the local paper that another facility in the system that she works in is being investigated for Medicare fraud.

DISCUSSION QUESTIONS

1. Should Nicki quit her job, speak to her supervisor, and/or go over her head to others in the chain of command? Explain your answers.

2. What if Nicki quits her job and moves away?

3. Nicki has kept thousands of documents that she believes are fraudulent in nature. What should she do with these? Should she provide them to her supervisor? The media? Why or why not?

4. What laws, if any, are you familiar with that may help to protect Nicki? Explain your answer and detail the provisions of these laws.

5. In your mind, does this case present an issue of fraud, abuse, or both? Explain.

6. Pretend that you are Nicki. You want to do the right thing, but you aren’t sure what that is. Where do you start? Outline a path for Nicki to follow.

7. Think about your own experiences, no matter the working environment: Have you had to deal with issues of dishonesty? How have you handled it? What resources were or were not available to you?

8. Depending on your decision, i.e., do you leave, do you stay, do you do nothing, etc., are you liable if legal action is taken? Why or why not? Explain any actions that may be taken.

Answer 1

Ans: (1)

In my opinion, Nicki should go over her supervisor’s head and reach to the other people in the chain of command , in fact any type of fraud activity must be reported along with any sort of discrepancies. On the off chance that it is discovered that some child of misrepresentation was going on and she was additionally engaged with it , then she likewise needs to confront the abuse.

Ans:(2).

This issue is not going to be resolved simply by leaving the job and moving away. As I would see it , a solid stand must be taken by her and have some effect through the revealing of misrepresentation. By this means she will be able to help many individuals who have Medicaid and Medicare from being taken advantage of

Ans: (3)

In my opinion, All the documents should be handed over to “Health Care Fraud Prevention and Enforcement Action Team”. This is one of the strategies for her security and the reports can be explored by the group and in the event that it is required, moves could be made against the inside.

Ans: (4).

Nicki can use the Whistleblowers Act .

The Whistleblower Protection Act of 1989 (WPA) can be viewed as a law that gives assurance to the representatives of government workers in the United States from any kind of retaliatory activity for willfully revelation of data about exploitative or illicit exercises happening at an administration association.

Ans: (5).

Yes, this issue brings the issue of fraud in front. The improper billing of claims can be seen as an act of intentional deception of the center and its supervisor.

Ans : (6).

I. Gather all Documents

a. double check to ensure that there are discrepancies

b. have documents ready and available for proof

II. Research the laws for protection

a. to make sure that she is protected, research the different laws that are in place that will protect her when she reports the fraud

III. Speak to others in the chain of command

a. try to talk another person of the chain of command other than the supervisor

b. if no progress or response, report fraud to the Health Fraud Prevention and Enforcement Action Team

Ans: (7).

As of now, I didn’t encounter any situation like this as such.

Ans: (8).

I will rule for staying and accepting a few activities as I would truly need this sort of misrepresentation to end. On the off chance that I leave the association and don't get the case front of proper offices , It won't feel great to me.If in future any action is taken against the fraud and agencies, there is a greater chance of me too be prosecuted. I can be charged for conspiracy; knowing that the documents were not be billed correctly and failing to notify the government.