Dr. Wendy Kurtz, is an ear, nose and throat specialist (ENT) in Portland Oregon. Dr. Kurtz provides ENT services locally to patients in her community through NosesRus, P.C. (NRU). Dr. Kurtz is one of six physicians in the practice, and all of the physicians are shareholders in NRU. Earlier this year, the NRU’s compliance officer, Ms. Stevie Budd, gave a presentation to all employees, including department directors, and senior managers on proper Medicare billing practices for ENT services. This included the fact that to bill Medicare for sinus surgeries, there must be documentation in the medical record to support the services are “medically necessary”. A few weeks ago, while visiting with the clinic’s the nursing department, Ronnie Lee, a nurse manager tells Stevie that Dr. Kurtz is performing medically unnecessary services on her patients. Additionally, Ronnie states that NRU has submitted bills to Medicare and received payment. Ronnie Lee cites examples of patients that underwent sinus surgeries without an initial throat exam or other imaging studies, such as a head CT, to support medical necessity. Upon hearing this information, Stevie realizes that she may need to conduct an investigation and brief the compliance committee on this particular concern raised.
Assumptions:
For purposes of this discussion, assume the following:
NRU is a private practice, consisting of 24 physicians, 12 nurse practitioners, and another 100 employees (clinical and administrative).
NRU is run by senior managers (CEO, CFO, CNO) that report to a Board of Directors.
The NRU Board consists of 6 physician shareholders and the CEO (non-voting member).
Johnny Rose, is the current CEO of NRU. Johnny has been with NRU for 15 years.
Dr. Ted Mullins is an NRU physician, shareholder, and the currently NRU Board Chair.
Dr. Wendy Kurtz is a physician shareholder in NRU.
NRU has a compliance program in place, but it has only been in place for 18 months.
As part of the compliance program, NRU has a compliance plan, code of conduct, and a non-retaliation policy that protects employees who report potential issues in good faith.
Stevie Budd reports directly to Johnny Rose, and the Board of Directors.
Instructions:
Group C-Johnny Rose, CEO NRU
Assume you are Johnny Rose. You are “the face” of NRU, and a liaison between staff and physicians. Stevie has just notified you of this potential violation of Federal law. In your post, address the following questions:
From your perspective, what concerns about this allegation and investigation do you think need to be communicated to Stevie?
What are two take aways learned from the experience?
