Fraud and Abuse Case Study

Fraud and Abuse Case Study

Care One is a well-known medical practice that serves a rural community that does not have a hospital. The physicians must admit patients to a hospital in the next town that is 30 miles away. Dr. Caremore is one of the most well-respected and well-loved physicians in the community, and people feel he is the best physician in the community. Dr. Caremore has learned that sometimes he must exaggerate a patient’s conditions in order for the patient to be admitted to the nearby hospital and he often times has his office staff call 911 in order to have patients transported from his office to the nearby hospital. He has told the nursing staff that he does this to try to make the patients appear sicker than they might be in hopes that the patient will meet the medical necessity requirements for admission. Dr. Caremore knows sometimes the patient’s family needs a break from caring for the patient and a few days in the hospital is often a big help to family members. He does not want them to have to drive 30 miles away to the hospital to be sent back home.

You are the office manager for the practice and one of the nursing staff comes and reports the scenario to you. What do you do? Identify the issues and how this should be handled. Support your reasoning.