Sam is a new Nurse Practitioner (NP) in an independent physician-owned primary care office located in a small community. He loves working with the patients and gets along very well with his coworkers. Normally, Sam will see a patient on his own, or with a female nurse, if the patient is female. However, Sam recently noticed that his time with a patient was coded and billed to Medicare as one of the physician’s time. He recalled the legal course in nursing school about Medicare and knew that NP’s time is reimbursed at 80% of the actual charge or at 85% of the physician’s fee schedule amount, whichever is the lesser. He also remembered that the physician he was billed under was not in the office that day. Being concerned, he reviewed some additional records and discovered almost all of his time was coded and billed to Medicare as one of the physician’s time. When he questioned the billing clerk about the coding, her reply was “the Physician Assistant’s and NP’s time are always coded that way.” Sam believes this may be fraud and does not know what to do. He needs the job, as there are not many opportunities to do this type of work in the community. Plus, making this issue public could damage his reputation – making it difficult to find work in the medical field at all. It could also impact his co-workers, and ultimately reduce patients’ access to primary health care. Sam wants to know what to do! 1. Describe the legal concepts of “up-coding” AND “incident to billing.” Then, analyze the facts using both of these legal concepts to explain why you think there was a Medicare billing violation or why you think there was no violation. 2. Assuming there was a Medicare billing violation, what are the possible criminal AND civil penalties for the violation (be very specific in your description of the penalties) AND against whom could they be brought? Be sure to explain why the person you identified is subject to the penalty. 3. First, list ALL options Sam has in this situation. Then, using your list of options, what would you recommend Sam do at this point? Be sure to explain your recommendation in detail.

Sam is a new Nurse Practitioner (NP) in an independent physician-owned primary care office located in a small community. He loves working with the patients and gets along very well with his coworkers. Normally, Sam will see a patient on his own, or with a female nurse, if the patient is female. However, Sam recently noticed that his time with a patient was coded and billed to Medicare as one of the physician’s time. He recalled the legal course in nursing school about Medicare and knew that NP’s time is reimbursed at 80% of the actual charge or at 85% of the physician’s fee schedule amount, whichever is the lesser. He also remembered that the physician he was billed under was not in the office that day. Being concerned, he reviewed some additional records and discovered almost all of his time was coded and billed to Medicare as one of the physician’s time. When he questioned the billing clerk about the coding, her reply was “the Physician Assistant’s and NP’s time are always coded that way.” Sam believes this may be fraud and does not know what to do. He needs the job, as there are not many opportunities to do this type of work in the community. Plus, making this issue public could damage his reputation – making it difficult to find work in the medical field at all. It could also impact his co-workers, and ultimately reduce patients’ access to primary health care. Sam wants to know what to do! 1. Describe the legal concepts of “up-coding” AND “incident to billing.” Then, analyze the facts using both of these legal concepts to explain why you think there was a Medicare billing violation or why you think there was no violation. 2. Assuming there was a Medicare billing violation, what are the possible criminal AND civil penalties for the violation (be very specific in your description of the penalties) AND against whom could they be brought? Be sure to explain why the person you identified is subject to the penalty. 3. First, list ALL options Sam has in this situation. Then, using your list of options, what would you recommend Sam do at this point? Be sure to explain your recommendation in detail.