The second issue you have found comes out of your review of the department that submits bills to Medicare, Medi-Cal and commercial health plans for hospital services ("Billing Department"). The Billing Department had a long-standing program where it had a single employee monitor changes in the Medicare rules to ensure that Medicare claims were submitted accurately. Three years ago, the employee who had this function, Joan Yeats, gave notice of her retirement. She agreed to train her successor, Marvin Canon. Marvin overlapped with Joan for 3 weeks and all reports are that Marvin received appropriate training. Marvin has many other tasks in his position with the Billing Department, as did Joan. Joan had estimated that about 10% of her time was spent following Medicare developments. You have a hunch that Marvin has not been as thorough in his efforts as is required for someone solely responsible for following Medicare billing changes.

It turns out that 2 years ago, Medicare changed one of its requirements for knee replacement surgeries. For 10 years ending December 31, 2 years ago, Medicare would not pay for knee replacement surgery for patients whose body mass index ("BMI") was 30% or greater. BMI measures body mass and indicates whether an individual is obese. Medicare for all subsequent periods provides that it will not pay for knee replacement surgery for patients whose BMI is 25% or greater. This change was over 2 years before you had time to identify this issue.

A patient's BMI is not indicated on the bills submitted to Medicare. Rather, providers are expected to document the patient's BMI in the medical record.

You have found that Regional Tech has been and is still billing Medicare for knee replacement surgeries so long as their BMI was less than 30. The Billing Department policies and training on this issue have not changed in 5 years.

As of this point, you see that the Medicare program has not audited any of Regional Tech's knee replacement surgeries for the last 3 years or otherwise asked for the medical records for any of the knee replacement surgical patients.

(Students, please note that these Medicare rules and descriptions of BMI and the percentages uses are fictional, just included in these facts for examination purposes.)For this assignment, please draft an internal memo to the CEO and Board of Regional Tech. In your memo, first provide a brief summary of the two issues you have identified. Then, for each of the two issues you identified, cover the following three topics:

1. Explain how you would further investigate this issue?
2. Provide your recommendations for how Regional Tech will resolve each issue?
3. Provide your recommendations for how Regional Tech can prevent a future occurrence of each issue?