Evaluative Reply 1
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School
Dixie State University *
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Course
3040
Subject
Law
Date
Jan 9, 2024
Type
docx
Pages
6
Uploaded by ConstableAlligator3863
Evaluative Reply Template
Directions:
Use the evaluative template to prepare each evaluative reply.
Select two peer videos to review to make evaluate relies as assigned below.
●
List name beginning A-G:
Evaluate LTC Nurses and Patient Ulcers AND Clinic Billing Manager
and Billing Errors
●
Last name beginning H-O:
Evaluate Hospital Pharmacists Medication Errors AND Clinic Billing
Manager and Billing Errors
●
Last name beginning P-Z:
Evaluate Hospital Pharmacists Medication Errors AND LTC Nurses
and Patient Ulcers.
Post each evaluative reply separately in its own post for 2 reply posts.
Copy and paste each reply into the BODY of the discussion post for discussion purposes.
----
Peer Reviewed:
Cole Van Ausdal
Topic:
Clinic Billing Manager Billing Concerns
Issue Description:
Issue 1:
Double billing, Patients were being billed for 1 visit and insurance for 2 visits on
different days.
Issue 2:
Selling PHI, Manager at clinic has been getting patient patients PHI and selling
it for money.
Issue 1 Evaluation:
Legal Evaluation:
False Claims Act: [31 U.S.C 3729]
I liked the 2 amendments that he pointed out which helped point out the specifics to what a false
claim is and that is that it is knowingly made and a material fact with respect to the claim.
The violation of this law has 2 different category of penalties and within those two categories has
multiple categories the two categories are criminal penalties and civil monetary penalties. With
how long this has been going on this will cost the clinic millions of dollars and fines.
Ethical Evaluation:
Deontology:
I like how he describe what deontology was and how it was made. Also, I like how
he applied it to the situation through the distrust of the clinic by them over billing the patients.
The ethical principle that applies to this situation is the violation of beneficence. I chose this
principle because this principle is described in making choices with the intent of doing good. By
the clinic double billing they did not follow the principle of beneficence. They violated this by
double billing which is not doing good on the patient’s part.
Compliance Resource
The HHS OIG compliance resource has many benefits to help stay compliant when dealing with issue we
run into. The main thing I liked about the HHS OIG was the self-reporting system. This will help not only
handle issue quickly but also gives employees accountability and responsibility of reporting activities.
This will help in situations like this because if an employee see the double billing it can be address
quickly and they will be able to see the double billing because of the monitoring that the HHS OIG also
provides.
The other compliance resource I would use is COSO because of the intergraded frameworks it offers. The
risk assessment would be the biggest thing to point out because by doing a risk assessment you could see
how high of a risk there is of someone double billing and could be addressed and things put in place to
prevent it like monitoring.
Issue 2 Evaluation:
Legal Evaluation:
HIPAA Breach Notice
[Utah Code 34-28-5(1)]
In this law I like how Cole explained the law and gave the requirements of the action the
of the information must do. As he stated there must be a notification to the patients involved and
media of the breach (in case the case of 500 or more patients were involved) within 60 days of
the breach. I also like in the state law he stated the action and employer can take to deal with the
situation as he states they can be terminated at anytime without notice. As long as their paycheck
can be provided within 24 hours.
The legal and ethical risk of this situation can be severe as on the federal level there can be criminal filing
to the clinical manager that was selling the PHI. The state level like stated above the termination of the
employee at any time. The ethics risk in this situation would have a great impact on the clinic as patients
will feel unsafe with providing them information and not trust that they are a good place to get care when
needed.
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Ethical Evaluation:
Code of ethics
Code of ethics is a great choice for this situation it provides a set of ethics that is followed by the
company that they are working for. I like this because it sets a high standard that is also simple
and gives a standard consequence for violation of the ethics.
When it comes to ethical theories Cole did not mention one, but I believe a great ethical theory in
this situation would be Deontology. The reason for this is because when it comes to the clinical
manager, she was not doing her moral duty. She has a moral duty to protect her patients PHI and
she was not protecting she was doing the opposite by selling it to people.
Compliance Resource
COSO compliance resource
I like this compliance resource for many reasons. Starting with how COSO aligns with laws and
ethics. This is a big part of why COSO is my favorite resource for compliance. By implementing
the COSO framework into the work place and in this situation it could see the risk that the clinic
has of people selling PHI and could put in controls to prevent it by restricting certain access and
monitoring who access the information.
Another compliance resource I think would be great for this situation is HHS Breach notice. I
like this compliance strategy because it gives an outline on what you need to do if there is a
HIPPA breach and gives you the requirements that you will have to meet. This would help in the
situation where there was a Breach and would help the clinic on what the next steps are.
Final Recommendation/Action plan Evaluation:
What I liked about my peer’s final recommendation is how he addressed the patients first.
He did this by paying back all of the over billed patients which corrects his double billing. Then
he addressed where the problem was coming from and gave an action to fix it by training them.
What I liked about the action plan for the PHI selling is the idea of creating new polices and
preventative measure to ensure they can not use personal emails and also can not copy and paste
making it so it is not as easy to access and retrieve the PHI.
My recommendation
I would to implement COSO in this situation of over billing and to implement HHS
Breach notice for the PHI incident.
Issue 1
Action step 1: I would be to help the Pay back the over billed patients to stay in compliance with
the law and by doing so fast and first show our patients in a way the are still are #1 priority.
Action 2: I would do a risk assessment to see what caused the over billing and address it with my
third action.
Action 3: When it comes to billing, I would see who was doing the over billing and implement a
control to monitor the billing so that it is prevent to happen again in the future
Issue 2
Action 1: I would terminate the manager and notify all parties that are required to be notified and
involved in the situation and let them know we are investigating and making sure will not happen
again as we have terminated the employee.
Action 2: I would do a risk assessment that tells me who has access to patients PHI and how
much of it
they have access to and what they can extract from that information.
Action 3: I would implement a monitoring system to monitor information that is accessed and
also limit access to who can see the patients PHI.
By doing this action plan and implementing COSO and HHS Breach it will help us stay
compliant with legal requirements and stay compliant with our ethical code and show patients
they can trust us and we are addressing the problem and it will not happen again.
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