Compliance Failure

Falsification of records and billing are serious offenses and must be treated as such. As a health administrator, you will be called upon to monitor staff to be sure that records and billing are accurate.

In this scenario, consider that you are the assistant manager of operations for the Smith Home Health Care Services. Part of your job is to do impromptu visits where internal audits are completed as a measure to monitor the home health nurses and aides for the company.

You have been observing Barbara Smithers, who has been a home health aide since the company was established in 1995. You notice, before one of your monitoring visits, that Barbara's billing totals seem higher than the average worker. When you observe her home services and compare them to the services rendered, there is a discrepancy. Going back in her service records, this has been a pattern for at least 4 years. You report this to your supervisor, Ron James. Mr. James meets with Barbara, who finally admits that she has been "padding" the billing for at least 10 years, at the demand of nursing supervisor, Donna Strickland. Mr. James asks you to sit in on a conference with Ms. Strickland and Ms. Smithers and contribute to questioning them and helping make a final decision.

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.

How did the Service fail in its responsibility in monitoring Barbara? Should the facility 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?

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?

Initial post should be 250-300 words ( excluding references).