Question

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.

Answer 1

●The documentation of patient are very confidential in healthcare sector.The medical coding and billing part of the documentation can trace the occurrence of any fraud.

●Once when a fraud is identified it has to be reported to the Department of Health and Human services Office of Inspector General or it can also be reported to the state Division of Medical Assistance. They then are designated to investigate the complaint and take necessary actions legally. When a fradulence is identified, it is legally punishable

●The legal repercussions to be faced are legal actions taken on the previous employees,scrutiny of the organization for further fradulence for monetary gains.When this happens it goes public,so the fame if the hospital may be lost,hope kept by patient on the agency are lost,a sense of disbelief occurs among the sick individuals to take treatment or service from them.It can jeopardize once career by working in that environment.

The new manager though not following any fradulence ,is a must to report the fraudulent practices done by the predecessor in any case. Concealing this is legally punishable to both parties.Doing so will stop the investigation from a prosecutor end, verifying the licensure and certification of the healthcare organization and finally its employees from the respective professional departments. The ethical consideration of beneficience by one party for the sake of monetary gains are not acceptable legally. When this is reported the HHSC-OIG takes necessary administrative actions or administrative sanctions accordingly. This can be exclusion ,suspension, cancellation or restricted from Medicaid payment, the overpaid Medicaid bills can be recouped.When a manager fails to report this there will be a financial loss to the state and federal government in a smaller or larger basis,This ultimately will reflect in the benefits provided under Medicaid can be ceased overtime due to financial crisis.