Identify the legal and compliance implications of the billing specialist’s actions.

Published by Jeannie R. Ferrell

Dec 8, 2022


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In your response posts to at least two other peers’ initial posts, respond to the following:
Compare and contrast your thoughts on the legal and compliance implications identified by your peers.
Explain one additional measure for preventing such actions that your peer did not discuss in their initial post. Why do you feel it is an essential measure?
First Discussion
Identify the legal and compliance implications of the billing specialist’s actions.
Billing errors and fraud impact more than just the revenue of a healthcare organization. It can also expose patients to unnecessary and risky procedures. The abuse and fraud could happen in a variety of different ways such as upcoding which is when an inaccurate level of evaluation-and-management code is used on a patient (O’Reilly, 2021). Another way it can happen is failing to check the National Correct Coding Initiative which was developed by the Centers for Medicare and Medicaid Services to ensure correct coding methods were followed (O’Reilly, 2021). The implications of these actions are that $95 billion of the $1.1 trillion the CMS spent on health coverage for 145 million Americans was connected to abuse or fraud. This results in inefficiency, high costs, and waste (Drabiak & Wolfson, 2020). These mistakes are costly for organizations as they may face penalties as well as delayed payments from insurers.
Describe how you believe the manager and hospital should respond to this issue.
The first thing the manager and hospital should do in response is make sure there isn’t a pattern and that other specialists are not committing the same mistakes. Second, making sure the organization self-reports issues to the CMS or state reporting entities is important so as not to seem complicit in hiding billing errors. Third, if it is found that the specialist was careless in performing their duties it should result in separation from that employee. If it was concentrated to a few billing errors then more training may be necessary.
Describe the measures the hospital should take to prevent the recurrence of this issue.
First, the hospital should look into technology that will help audit all claims and catch errors. Artificial intelligence can help identify potential anomalies and flag potential events (Drabiak & Wolfson, 2021). Additionally, the hospital should consider implementing a special program for new employees to address program integrity issues arising from mistakes and errors. But the number one measure the hospital could take is ensuring training is done and that employees understand the Federal False Claims Act (FCA), Anti-Kickback statute (AKS), the Stark Law, and the Criminal Health Care Fraud Statute.
O’Reilly, K. (2021). 8 medical coding mistakes that can cost you. American Medical Association.
Drabiak, K. & Wolfson, J. (2020). What should health care organizations do to reduce billing fraud and abuse. AMA Journal of Ethics, 22(3), 221-231. https://doi.10.1001/amajethics.2020.221.
Second Discussion
Hello everyone,
Healthcare fraud has several elements, including knowingly submitting false claims to obtain a healthcare payment for which no entitlement would otherwise exist (CMS, 2019). Fraud also involves getting or soliciting remuneration to induce referrals or making referrals to designated health services (CMS, 2019). If this billing specialist’s actions were to be found illegal, he would likely be in violation of the Federal Civil False Claims Act (FCA). The civil FCA enforces civil liability on individuals or organizations who knowingly submit deceptive claims to the Federal Government (CMS, 2019). The civil penalties include up to three times the amount claimed by the Federal government, a fine, and the possibility of being excluded from federal healthcare payment programs (Health Care Fraud, 2022). The hospital could be implicated in the penalties as the billing specialist is representing them.
The manager and the hospital need to perform several things to correct this issue. First, the manager must report the problem immediately to superiors or risk management. Once this reaches the latter, the organization must develop a mitigation plan that includes self-reporting the issue to a federal organization such as the Center for Medicare and Medicaid Services (CMS) or the Office of the Inspector General (OIG). These organizations have self-referral disclosure protocols available.
Both the manager and the hospital need to perform an enterprise risk assessment. Depending on the objective ranking of the risk inventory, disciplinary action can be taken against the employee (The Hanover Insurance Group, 2021). For example, this action is likely critical; therefore, the employee should be terminated. A fraud and compliance training program could be performed for the rest of the employees.
CMS. (2019). Medicare Fraud & Abuse: Prevent, Detect, Report. Center for Medicare and Medicaid.
The Hanover Insurance Group. (2021). Identifying risks in healthcare organizations
Health Care Fraud. (2022, October 11). Federal Bureau of Investigation.


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