We want to believe that all health care workers are honest, and operate with integrity. Unfortunately, there are quite a few people and organizations that have ulterior motives, and seek to take advantage of the system. Research Medicare/Medicaid fraud and abuse cases to establish a foundation of knowledge for this assignment.
Scenario:
You have recently been hired as the manager of a home health agency. You are a new graduate, have been interviewing for months, and finally landed this position – which you love! As you review the files in your new office, you discover some alarming information, which leads you to believe the previous manager was intentionally submitting incorrect information on Medicare patients, in turn, receiving an overage of reimbursement for the agency.
- Explain the documentation you found that led you to believe fraud had occurred.
- In a concise paragraph, summarize how you should proceed (i.e. who should be informed?)
- What legal repercussions could your agency face if you report this information? Will your job be in jeopardy?
Up to this point, you have examined the legal implications of this scenario. Now, consider the ethical obligation.
- If you commit to not continue the fraudulent practices of your predecessor, are you still obligated to report what you discovered? Address this question in approximately 500 words.
- Include the ethical theory that supports your response.
- A minimum of three references, in APA format, should be used for this assignment.
Expert Solution Preview
Introduction:
Medicare and Medicaid are two of the biggest health insurance programs in the United States. Unfortunately, there are instances where fraudulent practices take place, causing significant losses to the government. As a medical professor creating assignments and answers for students, it is important to incorporate real-world scenarios that align with the challenges faced in the healthcare industry.
Answer:
The documentation found by the new manager suggests that the previous manager of the home health agency intentionally submitted incorrect information on Medicare patients. This incorrect information led to an over-reimbursement for the agency through Medicare reimbursement. The documentation found includes cases where patients’ medical records were falsely documented to indicate that they required daily home healthcare visits when they did not. Additionally, there were instances of visits that were never completed but billed to Medicare.
The new manager should inform the governing board of the home health agency, the Office of the Inspector General (OIG), and the Medicare Administrative Contractors (MACs) of the suspected fraudulent practices. From there, these organizations will conduct thorough investigations into the matter and take the necessary legal measures to address the issue.
Reporting fraudulent practices has legal implications that could cause the agency to face civil and criminal penalties, including exclusion from Medicare and Medicaid programs. The actions taken by the new manager are protected under the False Claims Act, and no retaliation should be taken against them.
To address the ethical obligations, the new manager must report the fraudulent practices even if they commit to not continuing the practices of their predecessor. The ethical theory that supports this response is consequentialism. The theory of consequentialism focuses on the consequences of one’s actions, arguing that actions should be taken based on the outcomes they produce. In this case, failing to report the fraudulent practices could lead to the perpetuation of the actions, causing further harm to the government, Medicare beneficiaries, and the healthcare industry’s reputation.
Conclusion:
In conclusion, Medicare and Medicaid fraud and abuse cases are common in the healthcare industry. As a medical professor, it is essential to educate medical college students on the legal and ethical obligations of healthcare professionals in such scenarios. The proper reporting of such practices will ensure that healthcare providers are held accountable for their actions and that patients receive the appropriate care.
