Working in the billing department for a large, for-profit health care organizati

Question

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.

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

2. 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.

3. 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?

4. 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.

Explanation / Answer

1. If we analyse the situation carefully we saw that when Nikki reports to superior about the dicrepancy hw behaved weard as unexpected if there was only unintentional misatke then superior will correct it not instruct her like do you work. as in my opinion the superior abuse the authority that he had and also there is fraud as 1000s of invoices have same issue nor 1-2 invoices that can be ignored so here both abuse as well as fraud happens.

2. If I were at Nikki's place i will firstly go to supervisor as she did. if superior did not take my point seriously like in present case i will go to supervsior's boss i.e head of Department who have authority to monitor and take action if he also behave the same. i will go to the top mangement by writing them or whatever be the best possible way to communicate with them i will tell them how his juniors behave and took no action.

3.In an organisation a situation of dishonesty can be occurs. I will report the dishonesty to the superior person and also i will try to collect proof to support my point. may be i would get support from seniors or may be not. the resources that might be not available to me like any strong proof or the person against whom i was complaining had a good reputation so i had to deal with all that and save organisation from dishonesty.

4. I will prefer to stay and try my best possible to stop all this. Every person who is employed in a particular department are under investigation if any legal action going to taken. I have to prove my innocence that i was not involved and showed them my innocence in the matter. in case i was not able to stop all this even after reporting to top mangement i will prefer to leave such dishonest organisation as in case of legal action that will also effect my career.

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