Fraud and Abuse

Fraud and Abuse

Nicki should not quit her job. She should also not speak to her supervisor or others in the chain of command. They might all be involved in committing the crime. Besides, the law does not require her to report the crime to her supervisors (Szalados, 2021). The fraudulent documents she has kept can be taken to an attorney who deals with Medicare fraud cases. She should not provide the documents to her supervisor. These documents are incriminating evidence against him; therefore, the supervisor may destroy the records. Also, she should not give the documents to the media. The media is not a proper channel for reporting healthcare insurance fraud.

The False Claims Act of 1863 can protect Nicki. This law allows the government and its citizens to file a lawsuit against individuals who intentionally submit fraudulent claims to the government (Adashi & Cohen, 2022). The law enforces civil punishment against offenders. Additionally, it enacts a penalty of three times the loss incurred by theft. The False Claims Act prevents employers from firing or harassing employees who report fraudulent healthcare insurance activity.

This case presents an issue of fraud and abuse. It is a fraud case because there are inconsistencies in how Medicare bills are coded. Furthermore, Nicki was told they would continue to code with the irregularities after informing her supervisor about the discrepancies. The case is also an issue of abuse. Nicki is called a “Ms. Know-it-all” when she reports the fraudulent activities to her supervisor.

If I were Nicki, I would first ensure that I have adequate and proper evidence to support my claims. I would then seek legal advice from a Qui Tam Lawyer. A Qui Tam Lawyer is an attorney with professional experience in legal cases against organizations that have committed fraud. The lawyer will advise on the appropriate next steps after analyzing the situation. They could recommend reporting the case internally or filing a legal suit.

References

Adashi, E. Y., & Cohen, I. G. (2022). Health Care Fraud: The Leading Violation of the False Claims Act. The American Journal of Medicine, 135(5), 558-559. https://doi.org/10.1016/j.amjmed.2021.12.014

Szalados, J. E. (2021). Regulations and Regulatory Compliance: False Claims Act, Kickback and Stark Laws, and HIPAA. In The Medical-Legal Aspects of Acute Care Medicine (pp. 277-313). Springer, Cham. https://doi.org/10.1007/978-3-030-68570-6_12

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Working in the billing department for a large, for-profit healthcare 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 promoted to senior Medicare Billing Specialist. Since Nicki has been dealing with Medicare for over two years, she jumps right in, continues with the same billing practices she has been using, and trains her staff with these techniques.

Fraud and Abuse

Because Nicki’s new position allows her to view information she was not privy to, she has noticed discrepancies in how many 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 extraordinary, but she goes back to her work.
Six months pass, and Nicki has grown more distraught as she has collected thousands of coded invoices incorrectly, but she can do nothing to change them at her level. She feels uncomfortable approaching her supervisor again and is concerned that going higher up the chain of command may worsen it. To compound the problem, Nicki reads in the local paper that another facility in her system is being investigated for Medicare fraud.

Should Nicki quit her job, speak to her supervisor, and go over her head to others in the chain of command? Explain and cite reasons for your answers.
Nicki has kept thousands of documents that she believes are fraudulent. What should she do with these? Should she provide them to her supervisor? The media? Why or why not?
What laws, if any, are you familiar with that may help to protect Nicki? Explain your answer and detail the provisions of these laws.
In your mind, does this case present an issue of fraud, abuse, or both? Explain.
Pretend that you are Nicki. You want to do the right thing but aren’t sure what that is. Where do you start? Outline a path for Nicki to follow.