Case Study:

A registration employee in the cardiac catheterization laboratory noticed that one physician was providing the identical diagnosis as the reason for the procedure for all of his patients presenting for services in this department. None of the other physicians reported the exact same diagnosis for all of their patients. The physician in question also has a much higher number of referrals to the cardiac catheterization lab than other physicians. This employee does not have access to patients' medical records, so she cannot check to see if the diagnosis is supported by documentation in the patients' medical records.

1. What steps should the registration employee take given this atypical finding.What mechanisms would you implement to ensure that staff members are encouraged to report suspected or actual compliance violations?

1. What potential federal statute(s) or law(s) may be at issue here?

Application Questions:

1. To establish and maintain a comprehensive compliance program can be a challenge for any compliance officer, explain some of the challenges that you might face if you were asked to establish a compliance program as a new graduate. What barriers can you imaginably foresee given your education up to this point in the program? What are some potential solutions to the barriers that you identified?

Note: There are multiple resources available to facilities struggling to create and maintain a suitable compliance program. One resource is the Medical Learning Network (MLN) Provider Compliance program. Follow the link below to learn more about this resource:https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ProviderCompliance.html

1. Analyze the policy and procedure on Fraud, Waste and Abuse (FWA) that is posted on the class Moodle page. Do you agree that the establishment of a "Special Investigations Unit" (SIU) would be a good way to designate individuals within the facility to conduct auditing and monitoring for fraud, waste and abuse (FWA) surveillance? Do you feel that this policy explains their role sufficiently with regards to auditing and investigating suspected cases of FWA? Explain why or why not.

1. Within the policy and procedure on Fraud, Waste and Abuse (FWA) posted on Moodle, examine the section on "Protection Against Retaliation." Describe the concept of non-retaliation. Do you feel that this policy and procedure adequately addresses all potential issues associated with non-retaliation?