You have graduated from West Chester University and are now an administrator in a large orthopedic practice in Philadelphia, PA. There is strong demand for the orthopedic services and most of the patients that receive services are privately insured.
Case Study Directions
This case study analysis applies the material that has been covered in Chapters 9 – 15 of the Showalter text. Please read the following case study thoroughly and use the following format (I.R.A.C.) when answering the questions posed throughout the case study:
- a. I: Identify the Issue
- b. R: Identify the Rule: Please document the language of the rule(s) and its elements that is/are being applied to answer the question. Provide the citation from the source of the rule language.
- c. A: Apply the rule to the fact pattern
- d. C: Conclude with a recommendation to the physician or dentist.
Please complete the case study with the assistance of your text and any other research sources that you may find useful. All writing and editing must be your own without any assistance from any other person in the course. Complete the case study individually and without the assistance of your colleagues in HEA 513. All written text must be your work and yours alone.
Please use subheadings throughout the text to identify the case as well as the logical steps in the analysis. Please complete the case study with a maximum of five (5) pages, single-spaced, 12 pt font, with APA 6th Ed formatting. Provide citations for all rules and cases used in the case study. Please include a title page and separate reference page. The title page and reference page do not count towards the five (5) page maximum. Please include your first name and last name in the file name upon submission. For instance, save the file in this manner:
FIRSTNAME_LASTNAME HEA 513 Case Study II.docx
Please submit the case study to a dropbox on D2L no later than 11:59 PM ET on May 11. No late submissions of the case study will be accepted.
Please use your text reading to assist you. 2
Case Study II
You have graduated from West Chester University and are now an administrator in a large orthopedic practice in Philadelphia, PA. There is strong demand for the orthopedic services and most of the patients that receive services are privately insured. You are aware that the senior physician’s wife is an excellent physical therapist at the local hospital. The senior physician has stated that his wife is opening her own physical therapy practice just a few blocks away from the orthopedic practice. The physician states that it will be very convenient for the patients of the orthopedic practice to see his wife at her new practice given its proximity and quality care.
Although he has not asked you to consider the matter, you feel that this arrangement and potential referrals deserve a closer look. You take it upon yourself to do some independent research. After all, the physical therapist is a close friend and was a classmate in undergraduate school. You are aware she is the best in the business.
In your research, you also discover that the senior physician will be investing in his wife’s new physical therapy practice and will share in the financial profits as well as the losses. The physical therapy office will also use the same organization as the orthopedic practice to generate bills and submit claims to payers. The services provided at the physical therapy office will serve a critical need of the orthopedic practice as it will allow patients to recover from their surgeries as well as possibly avoid procedures that could be best treated by therapeutic services.
Both the senior physician and his wife have no intention of breaking any laws and are unaware of any health care regulations that they may be breaking.
What advice do you give to the senior physician and his wife?
Another friend is a dentist who has a large geriatric practice with nursing home patients throughout Chester County. The dentist typically visited the residents and conducted routine dental examinations in an office specifically set up by the nursing home. As part of the routine exam and without the request of an attending physician or because of any medical concern, the dentist would also conduct an oral cancer screening. The dentist would then bill Medicare for both the routine dental exam and the oral cancer screening.
In his own mind, the dentist never knowingly presented a false claim to be reimbursed by Medicare. But, he also deliberately never researched any of the laws or regulations to determine if conducting the additional oral screening was within a routine exam description. He openly bragged to his colleagues at the latest dental conference in Las Vegas that he also did not care whether he was breaking any law because he had not been caught yet and the pay was generous from Medicare and TRICARE. He bragged that if he “didn’t know it was wrong, it could not be breaking the law” and he was not going to take any additional measures to find out. 3
You recently became aware of your friend’s actions because your loved one is a resident at one of the homes where the dentist’s visits.
What advice would you give to the dentist after reading Chapter 15 of Showalter and consulting the case United States v. Lorenzo.
In another scenario, you have a friend, Robert Baratheon, who is a physician, and whose ex-wife, Cersei Lannister, owns a durable medical equipment supply company, Lannister Home Care, in King of Prussia. Dr. Baratheon can refer patients to the durable medical supply store where they obtain their hospital beds, walkers, crutches, oxygen bottles, and motorized scooters, among other supplies. The patients receive a special discount when they are referred to Lannister Home Care and they greatly appreciate the savings. Many of the patients would not be able to afford their purchases without this discount and this referral pattern has saved the patients tens of thousands of dollars.
In turn, Lannister Home Care gives a monthly bonus to your physician friend based on the sales that the patients referred by his practice generate in equipment and supplies. Your friend is under the impression that the monthly bonus is given to him because he provides patients a list of all durable medical equipment stores in the area. In his mind, there is no overt referral to Lannister Home Care. However, the bonus increases and decreases based on the number of patients that come from his practice. The Dr. Baratheon never sees these increases and decreases in the bonus because his billing manager intentionally never reveals it to him and he never knows to ask. He just assumes that all is being lawfully run. Lannister Home Care bills Medicare or the patient’s health insurance company if the item is covered by the patient’s insurance plan.
What advice do you give to your friend, Dr. Baratheon?
In 2005, another physician friend, Jaime Lannister (twin brother to Cersei) who lives in Westeros became one of the owners of a 50-bed physician specialty hospital that specializes in knee, hip, and shoulder replacement surgeries. He is a member of a group of physicians who own 100% of the hospital and perform all their replacement surgeries in the hospital. The group of physicians hires all the staff and has purchased all the equipment at fair market value. Your friend sees all his patients at a separate office and refers all patients that require replacement surgeries to the hospital that is owned by the physician group, of which he is a full member.
What advice do you have for your physician friend after the Affordable Care Act went into effect in 2010?
In another case in Miami, FL, Euron Greyjoy, owns and operates a purported addiction treatment center and home for recovering addicts. He is the leader of a scheme involving recruiting addicted patients to move to South Florida for opioid abuse treatment. Mr. Greyjoy sends out patient recruiters to Emergency Rooms and Medication Assisted Treatment facilities throughout the US. The recruiters identify patients that seem to be 4
wealthy and paying for their treatment out of their own pocket or are covered by private insurance or Medicaid.
The addicts are lured to South Florida with promises of permanent cures of their opioid addiction. They are shown flyers of beautiful large resorts with white sandy beaches where they will receive treatment. They were offered beach-side facilities with spa-like luxury. Amenities included golf therapy and rap music education. Some promise near-painless detoxification from even the worst opiate addictions.
All their travel expenses are covered to South Florida. They are urged to bring all insurance documentation with them and are met at the airport to be chauffeured to the “treatment” facility.
The patients and the patient recruiters are then offered kickbacks in the form of gift cards, free airline travel, trips to casinos and strip clubs, and drugs. The patients never receive the promised addiction treatment services, but Mr. Greyjoy and his co-conspirators submitted claims to the federal government for $141 million in false billings for services including home health care, mental health services, and prescriptions.
Mr. Greyjoy has come to you for advice regarding his business. What are your recommendations for Mr. Greyjoy and upon what law(s) are they based?