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.