SBAR Assignment
Nancy McCollough
Arizona State University
HCR: 265
Regulatory Essentials II
Amy Langord
April 28, 2023
Situation
Key Issues: Robert McGrath Jr and Robert McGrath Sr intentionally billed Medicare for services
they did not provide.
Summary: Robert McGrath Sr and Robert McGrath Sr were chiropractors who owned their own
medical clinic which had two locations in New Jersey and Pennsylvania (NJ District Court,
2017). They billed Medicare, under their NPI’s, but were either not present while the services
were being done or did not provide one-on-one therapy, which was what was billed (NJ District
Court, 2017).
Background
Linda Stevens reported on July 29, 2015, that Robert McGrath Sr and Junior had committed
Medicare fraud (NJ District Court, 2017). Linda Stevens reported this through the whistleblower
act (NJ District Court, 2017). The court found that from 2011 to 2016 both physicians directed
their staff to bill for services not provided or supervised to Medicare (NJ District Court, 2017).
The doctors billed for individual physical therapy services that were either provided by
unsupervised, unlicensed staff or were done in a group setting (NJ District Court, 2017). The
court then goes on to list specific events that happened in 2013 and 2014, in two of the specified
cases the physician that was listed as providing the service was at the other clinic which was in
another state.
The clinic in question was owned and operated by Robert McGrath Sr and Robert McGrath Jr,
they would have had more authority in the clinic than if they were in a larger health system. They
also could have been lacking adequate compliance staff. Billing staff should have noticed that
they were being instructed to bill Medicare on days that the doctors were not present. They
should have also begun investigating previous claims to Medicare at this point as well. The
unlicensed staff that did provide services should have been aware that the services need to be
supervised or done on a one-on-one setting. The office manager should have been made aware of
these inconsistencies and they should have investigated.
Assessment
This issue could have been prevented by staff speaking up when they were providing services
they should not have been and with more staff awareness and more training for the providers and
staff. The billing representatives and the provider staff were the ones that were directly
interacting with the fraudulent actions. Further fraud could have been prevented by reporting
these events at an earlier date, and by self-reporting, which could have lessened the punishment.
While the doctors and related staff members have not come out to give their motivations behind
their actions, it can be assumed that the doctors knew what they were doing. In the court case it
mentions that the claims that were billed were done under the direction and supervision of the
doctor (NJ District Court, 2017). This shows the intention in their actions. If the staff or
providers had a better knowledge of the self-reporting protocol and reported the mis-billings,
they might have been able to avoid prison and pay a lower fine.
Recommendations
If I were the compliance officer in this situation and had just heard about possible fraudulent
billings to Medicare, the first thing I would do is monitor the situation. Monitoring the situation
would allow me to compile data that shows the dept of the situation and the risk to the clinic and
providers (Limmroth et al., 2022). If the monitoring shows the same trend as the reported
incidents, the next step would be reporting and repaying Medicare as needed.
After reporting, a corrective action plan would need to be put in place. This would need a team
including me as the compliance staff, a member billing, a member of training, and a supervisor
of the provider staff. With this interdisciplinary team we would assess the further risk.
This is where training comes in, there would be refresher training for every staff member
regarding Medicare billing guidelines as well as self-reporting guidelines. This training would
be created by the compliance staff with consultation from billing and Medicare experts.
We would also discuss new policies for processing claims that would allow the billing
representatives to have their own supervisors rather than the doctors. This would take away any
element of intimidation from the providers to bill fraudulently. Appointing a supervisor in that
department would also provide them with a subject matter expert to consult for billing questions.
References
Limmroth, S., Muscio, D. A., Seykora, A., Allie, M., & Derricks, J. P. (2022). Monitoring. In
Complete Healthcare Compliance Manual (pp. 411–417). essay, Society of Corporate
Compliance and Ethics & Health Care Compliance Association.
United States of America v. Robert Christopher McGarth (United States District Court District of
New Jersey June 13, 2017).
