You are an employee of Big Hands Home Health Agency and are responsible for assigning RNs, LPNs, and CNAs, to go out to homes to care for clients. The owner of the agency, Lotta Gamble, is rarely around because she is out “scouting business.” In reality, she takes a lot of cruises, which she posts about on Instagram and Facebook and brags about all the gambling she does in international waters.
One day, you receive a call from an elderly woman’s daughter. “My mother says she hasn’t seen any one from Big Hands in a month—but she received bills for a daily RN visit.” You tell the woman that your boss is out of town, but as soon as she returns, you will let her know and get back to them. A few days later, you receive a similar call from another family. And then another and another. You are starting to see a pattern. Since the boss has taken her computer with her, you have no way to follow up. It will have to wait.
When your boss returns from her latest Caribbean cruise, all tanned and rested, you brief her on the assignments and employee issues. You then say, “And, we received calls from several families saying they were billed for services they didn’t receive. I told them I would investigate and get back to them. I’m guessing this is just a case of typing in the wrong numbers?” You hope.
Your boss says in a low voice, “Have you mentioned this to anyone else?”
You shake your head. “No, I waited to talk to you.”
“Good girl. I knew I could count on you.” She reaches into her purse. “I had a good streak on the backgammon tables. Here’s a five-hundred-dollar bonus for you. Let’s keep this little matter to ourselves, shall we?”
Those who commit crimes, including healthcare fraud and abuse, require need three things: motive/desire, opportunity/means, and victims/patients. Motives to commit fraud and abuse include, but are not limited to: jealousy, greed, anger, financial difficulties, feeling underappreciated, and, the thrill of a challenge.
What motives do you see in this case?
What opportunities/means do you see in this case?
Who are the victims of this fraud and abuse?
What laws might Lotta Gamble be violating?
Are the patients violating any laws or are they victims?
What regulatory agencies have jurisdiction over this matter?
Who should investigate this home health agency?
What are the potential penalties for Lotta?
If you take the $500 bonus and remain quiet, have you committed a crime?
Should you report this? If so, who should you call? What evidence do you have?
Should you be updating your resume and looking for a new job?
Support your responses with scholarly articles and rationales.
(Doesn’t have to be anything long)
Sample Answer
Sample Answer
Motives:
In this case, the primary motive for Lotta Gamble’s fraudulent behavior appears to be greed. She is taking advantage of her position as the owner of the home health agency to bill clients for services that were not provided, resulting in financial gain for herself. Additionally, her extravagant lifestyle, as evidenced by her frequent cruises and gambling activities, suggests a desire for personal indulgence and luxury.
Opportunities/Means:
As the owner of the agency, Lotta Gamble has the means and opportunity to commit fraud and abuse. She controls the assignment of staff members and has access to client information, allowing her to manipulate billing records and falsely charge for services that were not rendered. Her absence from the office for extended periods further facilitates her ability to carry out these fraudulent activities without detection.
Victims:
The victims of this fraud and abuse are the elderly clients and their families who are being billed for services they did not receive. These vulnerable individuals rely on the assistance of home health care professionals to maintain their well-being and quality of life. By fraudulently billing for services that were not provided, Lotta Gamble is not only exploiting their trust but also potentially jeopardizing their health and safety.
Laws Violated:
Lotta Gamble may be violating several laws related to healthcare fraud and abuse, including but not limited to:
False Claims Act: Billing for services not rendered constitutes submitting false claims for reimbursement from Medicare or other insurance programs.
Anti-Kickback Statute: If Lotta Gamble is providing kickbacks or bonuses to employees as an incentive to participate in fraudulent billing practices, she would be in violation of this law.
Health Insurance Portability and Accountability Act (HIPAA): Lotta Gamble’s actions may involve improper use or disclosure of protected health information, violating patient privacy laws.
Patients as Victims:
The patients are victims in this case, as they are being unknowingly billed for services they did not receive. They are innocent parties who rely on Big Hands Home Health Agency for their care and trust that accurate billing is being conducted. They are not violating any laws; rather, they are being exploited by Lotta Gamble’s fraudulent activities.
Regulatory Agencies with Jurisdiction:
Several regulatory agencies have jurisdiction over this matter, including:
Office of Inspector General (OIG): Responsible for investigating Medicare and Medicaid fraud and abuse cases.
Centers for Medicare & Medicaid Services (CMS): Oversees Medicare and Medicaid programs and is responsible for ensuring program integrity.
State Medicaid Fraud Control Units (MFCUs): State-level agencies that investigate and prosecute Medicaid fraud.
Investigation Responsibility:
Given the severity of the fraud and abuse occurring at Big Hands Home Health Agency, a comprehensive investigation should be carried out by the Office of Inspector General (OIG) or the State Medicaid Fraud Control Unit (MFCU). These agencies have the expertise and authority to thoroughly examine Lotta Gamble’s fraudulent activities, gather evidence, and pursue legal action if necessary.
Potential Penalties for Lotta:
If found guilty of healthcare fraud and abuse, Lotta Gamble could face severe penalties, which may include fines, imprisonment, exclusion from participating in federal healthcare programs, and the requirement to repay any ill-gotten gains. The specific penalties would depend on the laws violated, the extent of the fraudulent activities, and any aggravating factors discovered during the investigation.
Personal Criminal Liability:
If you accept the $500 bonus offered by Lotta Gamble and remain silent about the fraudulent activities, you may be considered an accomplice or participant in the fraud. While it is essential to consult legal counsel for a definitive answer, accepting the bonus could potentially implicate you in criminal activity.
Reporting and Evidence:
You should report this fraudulent activity to the appropriate authorities promptly. Contacting the Office of Inspector General (OIG) or your local State Medicaid Fraud Control Unit (MFCU) would be appropriate. Gather any evidence you have, such as phone call records from concerned family members reporting the fraudulent billing and any other documentation that supports their claims.
Considerations for Job Search:
Given the unethical behavior exhibited by Lotta Gamble and the potential legal consequences associated with her actions, it would be prudent to update your resume and actively seek alternative employment opportunities. Working for an employer who engages in fraudulent activities can not only compromise your professional reputation but also expose you to potential legal consequences if you remain associated with such behavior.
