• If accusations turn out to be true, what would be your recommendation in this case be to the Mr. James? What records do you need to review before the conference? Be sure to cite standards from the False Claims Act.

I would recommend to Mr. James to carry out an audit of all the billing claims in the institution. Similarly, a plan of correction will help to bring accuracy. Moreover, Mr. James should come up with a monitoring system that will help to ensure the fraudulent behavior does not repeat among the employees. However, before the conference I would thoroughly review the records from the last ten years. The records will entail the number of hours worked by Barbara and other aides. According to Showalter (2012), the False Claim Act states the following:

Knowingly presents, or caused to be presented, to an officer or employee of the United States a false or fraudulent claim for payment or approval. Second, knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claim paid or approved by the Government. Third, conspire to defraud the Government by getting a false or fraudulent claim allowed or paid. (p. 437)

• How did the Service fail in its responsibility in monitoring Barbara? Should the facility also be held responsible?

According to the records, Barbara has had a pattern for at least four years and also she has been “padding” for the last ten years. From the results, it is clear that there was a system failure, and hence there was no consistent monitoring of the claim records. According to my opinion, the facility should also be held responsible.

• Could the Service have avoided this situation? Does 4 years of potential fraudulent billing seem a reasonable time period for no one to notice?

Yes, the situation could have been avoided since it was merely a system failure. However, the health care administrator should take the responsibility of ensuring that corporate compliance programs are used well to verify the accuracy of the claims.

No, four years does not seem to be a reasonable time for no one to notice the discrepancy. The standards require the management of the health care facility to have mechanisms that will assist in verifying the accuracy of the institution’s claims.

• What are the consequences of this behavior? Is there a criminal case here? What about civil liability? Are there any non-monetary consequences this Service should now be worried about?

The following are the consequences of such behavior. They include civil penalties, loss of participation in both Medicaid and Medicare, criminal convictions. Also, the accused may be given a fine ranging from $5,500 to $11,000 per claim according to False Claim Act (FCA).  Yes, there is a criminal case and also a civil liability. Also, there are non-monetary consequences, and the service should get worried.  The service should be worried about their reputation that is at risk.

References

Showalter, J. S. (2012). The Law of Healthcare Administration. (6^th ed.). Chicago, IL: Health Administration Press.

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