Reference no: EM133565183

Hypothetical

Ipswitch Medical Center ("IMC") is located in North Plate, Nebraska. IMC has had a compliance program in place for several years, with an appointed compliance officer, Henry Hill.

On Monday, Henry receives an anonymous report from his compliance hotline alleging the scheduling staff in IMC's freestanding imaging center have been accepting invalid physician orders for patients who have received high dollar imaging exams (e.g., MRIs and CTs). The caller explains that as a result of these invalid orders, IMC has inappropriately billed patients' insurance. As often is the case with anonymous reports, the information Henry received is limited, so he is not able to speak with the caller.

Assumptions

For purposes of this discussion assignment, assume the following:

There are Federal regulatory requirements, through the Code of Federal Regulations (CFR) and CMS Medicare Billing Guidelines (such as a Claims Processing Manual, Benefits Manual, and National Coverage Determinations) that generally require the following elements for a physician order to be valid and billable to Medicare:
Patient's name;
The test requested;
Reason for visit;
Name of the treating physician; and
Signature of the treating physician.
Due to the complexity of the exams, time, and available resources, assume these imaging exams have to be scheduled in advance (as opposed to a walk-in x-ray). Additionally, assume there is a scheduling department at IMC, offsite from the freestanding imaging center. It is the scheduling department's responsibility for ensuring all the required documentation is in place from the referring/treating physician before the exam is performed. Lastly, as it relates to the scheduling department, currently there are no standardized procedures in place for assembling this documentation prior to the exam. Each scheduler is responsible for ensuring the documentation is in place.
Assume you are Tony Stacks, the Director of Medical Imaging at IMC. Upon receiving the hotline call, Henry contacts you to set up a meeting to discuss this issue. Since you have oversight for the imaging department, you are concerned about non-compliant billing and potentially refunding claims for services provided. This has been a difficult year for the department as patient volume has been down. Since these are scheduled exams, you feel the scheduling department staff dropped the ball. That said, you are open to working with Micki in order to resolve the issue. On your slide, respond to the following question:

What steps could you take to assist Henry with his investigation and what organizational or department related process recommendations do you have to prevent this issue from happening again?
Assume you are Micki Conway, the supervisor for the IMC scheduling department. You are equally concerned about this issue, but since you're staff are not onsite when the patient arrives, you feel the staff that report to Tony (either registration or imaging techs) should be verifying the order as well. That said, you have worked with Tony for several years and open to figuring out a solution that works for everyone. Henry has just contacted you to follow-up about the call he received and his investigation. On your slide, respond to the following question:

What steps could you take to assist Henry with his investigation and what organizational or department related process recommendations do you have to prevent this issue from happening again?
Assume you are Henry Hill, the IMC Compliance Officer. You are tasked with investigating this matter. At this point, you are in a position of gathering facts and therefore need to talk to both Tony and Micki in order to determine the root cause of the issue. On your slide, respond to the following question:

Describe what steps you would take to investigate and resolve this matter? (e.g., who do you want to take to, what information do you need to resolve?)
Assume you are the CEO of IMC who reports to the Board of Directors. You have been with the organization for several years, but recently your patient volume has been down due to a new competitor that has entered the market. The Board has expressed concern about your performance and established new goals under your employment contract. You are also a member of the IMC Compliance Committee. Henry reports to you directly, and he has just notified you of this potential violation of Federal law. On your slide, respond to the following question:

As the face of the organization, what concerns do you have about this issue and the investigation that you feel Henry needs to know?