The CFO is very excited to have you on board to advise on complicated billing and coding
Question:
The CFO is very excited to have you on board to advise on complicated billing and coding issues. For example, she wants to know whether it is appropriate to code transfers of post-acute patients from the hospital to the nursing home as a discharge from the hospital. She could code it as simply a transfer between entities, but because the nursing home and hospital are owned by the same company, she is concerned that doing so may violate the Stark Law. At the same time, because the hospital and nursing home are incorporated as separate entities, she thinks coding it as a discharge not only is appropriate but generates more revenue for the hospital.
She informs you that the department is currently understaffed due to the recent termination of a billing clerk. She says that it is poor timing because, over the last year, insurers have rejected an increasing number of claims. When you ask why the billing clerk was terminated, the CFO explains that she was fired because she routinely used her computer workstation during work hours for booking personal travel and buying on e-Bay. The CFO confides in you that, just prior to her termination, the billing clerk's sister, who works in the nursing home, told the billing clerk that unlicensed nurses at Mystic Nursing Home were administering medications to residents, and the billing clerk threatened to disclose that to the OIG. The CFO called a friend of hers at the nursing home to see if that was actually true but was told that all the nurses were licensed. The CFO decided not to inform any of the other senior staff about the threatened call to the OIG hotline because she was certain it was a lie.
1. What are the legal and/or compliance issues raised by the hypothetical?
2. What law, regulation, or governance requirement/policy MAY have been violated? Consider among the following and explain why a potential violation may have occurred.
- Federal False Claims Act
- Physician Self-Referral "Stark" Law
- Federal Anti-Kickback Statute
- Federal Tax-Exempt Law
- Emergency Medical Treatment and Labor Act (EMTALA)
- Health Insurance Portability and Accountability Act (HIPAA)
- Antitrust Law
- Organizational bylaws
- Scope of practice laws, licensure, certification
- Employment law, corporate liability
3. Which issues merit highest priority? Why?
4. Which issues would you recommend for further investigation? Why?
5. What, if any, further steps would you suggest (e.g., referral to inside/outside counsel, involvement of additional departments or individuals, revision of policies/procedures, termination of employment or contractual relationships, self-reporting to the government, internal audit, etc.)?
Auditing A Practical Approach with Data Analytics
ISBN: 978-1119401742
1st edition
Authors: Raymond N. Johnson, Laura Davis Wiley, Robyn Moroney, Fiona Campbell, Jane Hamilton