NU677 Unit 6 Assignment
Fraudulent Billing Practices
Create a PowerPoint presentation regarding billing fraud based on the provided case study. Identify the fraudulent billing practice(s), if the fraud is reportable, and where to report the fraud.
Case Study
Mark is a new psychiatric and mental health nurse practitioner. He has 10 years of inpatient psychiatric nursing experience, but this is his first job as a nurse practitioner. He was very excited to start working in the outpatient clinic with one of the psychiatrists that admits patients to his unit and feels he knows very well. He seems supportive of nurse practitioners, as three work in his office with him.
He enjoys his job, has supportive co-workers happy to show him the ropes, and is learning a lot. After only two months, Mark receives a check from the office manager as a “retention bonus.” Mark is confused because he did not recall discussing a bonus during his interview and hiring process.
One day, Mark is out to lunch with a fellow graduate of his nurse practitioner program. They are discussing their new roles as providers. Mark mentions some billing practices and “retention bonus” to his friend. Mark reports:
“Things are going well at the new clinic. I like my co-workers, and the pay is great. They gave me a retention bonus after only 2 months of working in the clinic. It is really helping to pay off the student loans.
We have patients scheduled every 15 minutes, so that is a little tough, but the pay! It’s worth it.
We just have to make sure we document we are seeing the patients for thirty minutes to make sure we cover the administrative costs of the extra services we provide to our patients. We have nurses that make reminder phone calls, they call in all our refills for us, they handle all of the controlled substances, and we waive patient copays. It’s great, frees up my time, and the patients seem happy. I am not taking work home at night. I have heard others that are struggling to keep up.
We just have to call the physician and touch base with him at the end of the day to make sure he is on board with our treatment plans. That’s kind of annoying because he can be hard to get in touch with sometimes. He gives a lot of those pharmaceutical lectures at night. A lot of times, these pharmaceutical representatives will take the practice out to dinner, and they are always buying us stuff.”
Mark’s friend asks if the billing is incident to, direct pay, or shared/split.
Mark responds, “Since we touch base with the psychiatrist every night, we bill incident to.”
Mark’s friend points out that these billing practices seem fraudulent, and he is concerned that Mark can get into big trouble. Mark gets upset and states his friend is jealous of all the money he is making.
Mark begins to feel uncomfortable the next day at work and starts noticing some things. During one of his medication review appointments, a patient complains that the pharmacy he sends prescriptions to is very expensive because it is not in their insurance network. After the appointment, Mark talks with the nurse to ask her to send the prescriptions to a different pharmacy in the patient’s network. The nurse responds, “We only send prescriptions to Marty’s Pharmacy. If the patients want the prescriptions sent to another pharmacy, they have to pay a refill request fee and are billed a nursing visit because it takes extra time to change the pharmacy and resend the prescriptions. This is one of the perks we offer to our patients.”
Mark researches Marty’s Pharmacy and sees the pharmacy is owned by one of the nurse practitioners in the office, and her husband is Marty. He now suspects that his “retention bonus” may be a kickback for the prescriptions he sends to the pharmacy. Mark is growing uncomfortable at work but doesn’t know what to do.
Use the following format for the PowerPoint presentation:
Slide 1: Introduction
Slide 2: Requirements of incident to billing
Slide 3: Is this practice committing fraudulent or illegal practices? What are fraudulent and/or illegal practices? Why are they fraudulent or illegal?
Slide 4: What obligations and roles do nurse practitioners have in preventing waste, fraud, and abuse? What are the most common fraudulent practices in healthcare?
Slide 5: What are the potential consequences or penalties for this practice if found guilty of healthcare fraud?
Slide 6: To whom does Mark report the suspected fraud? What happens if no fraudulent practices are found? What happens to Mark if fraudulent practices are found?
Slide 7: Conclusion
Slide 8: References
Use voiceover or Youtube to present your presentation. Use at least one reference from the reading list to support your conclusion regarding the billing practice.
Assignment Requirements:
Before finalizing your work, you should:
Be sure to read the assignment description carefully (as displayed above).
Consult the Grading Rubric (located in Course Resources, Grading Rubrics submodule) to make sure you have included everything necessary.
Utilize spelling and grammar check to minimize errors.
Your writing assignment should:
Follow the conventions of Standard English (correct grammar, punctuation, etc.).
Be well-ordered, logical, and unified, as well as original and insightful.
Display superior content, organization, style, and mechanics.
Use APA 7th edition format.
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