HI545 Unit 9 Investigation Memo Example

Eleven Weeks Before the First Monthly Screen: A Unit 9 Investigation Memo on an Excluded Agency Sleep Technologist

[Student Name]

Purdue University Global

HI545: Health Care Compliance

Unit 9 Investigation Memo

[Instructor Name]

[Date]

Esterline Health, the technologist, the agency and every count are composite; the statutes and guidance cited are real.

Header

To: Chief Compliance Officer; General Counsel. From: Compliance Investigator. Re: Possible exclusion match, agency polysomnographic technologist, sleep laboratory. Privileged and confidential; prepared at the direction of counsel.

Summary

On the first monthly screen run under revised policy COMP-114, a travel polysomnographic technologist placed in the pulmonology practice's sleep laboratory by an outside staffing agency matched an entry on the inspector general's exclusion list. Identity is confirmed. She worked 37 night shifts over eleven weeks and took part in 212 sleep studies that were billed. She was removed from duty the day the match was confirmed. The agency's contract required it to screen her and it reported that it had.

Background

Under the old policy, agency staff were not screened by Esterline. The revised policy, approved in Unit 3, requires Esterline to screen every placed worker before start and monthly. The technologist began work three weeks before the policy took effect, so she was never screened at start. The first monthly roster screen ran eleven weeks after her first shift.

Investigation Steps

1. Identity. The screening vendor's possible match on name was compared with the list entry's date of birth and the technologist's state credential number, and confirmed through the list's verification process. Strength: established.

2. Exclusion status. The list entry shows an exclusion effective four years ago, under the mandatory authority for a health care fraud conviction, with no reinstatement. Strength: established.

3. Duties. Schedules, the sleep laboratory's study logs and her login history in the sleep scoring software show which studies she set up, monitored or scored. Strength: established for 212 studies; for nine further studies her name appears on the schedule but not in the logs, so her involvement is uncertain.

4. Claims. Each of the 212 studies was traced to its professional and technical claims by account number and date. Of these, 168 were billed to Medicare or Medicaid and 44 to commercial payers only. Strength: established from billing records.

5. Agency screening. The agency produced a screening report for her dated before placement. The report shows a search of a state list only, not the federal list. Strength: established from the document; the reason for the omission is not yet known.

6. Knowledge. No Esterline employee interviewed knew of the exclusion. The sleep laboratory manager said the agency's credential packet showed an active state credential and nothing else. Strength: supported by interviews, not independently verified.

Every finding carries its strength, so the committee can see which facts are settled by records and which still rest on someone's word.

Applicable Rules

Work done by an excluded person is not payable by federal programs even when someone else's number appears on the claim, so a technologist's part in a study billed by the practice falls under the bar (Office of Inspector General [OIG], 2013). A provider that presents claims for such services, or contracts with an excluded person, may be liable for civil monetary penalties when it had actual or constructive knowledge of the exclusion (42 U.S.C. § 1320a-7a, 2024). The OIG's self-disclosure protocol accepts disclosures involving the employment of or contracting with excluded persons and sets out what such a submission must contain (OIG, 2021).

Open Questions for Counsel

1. Whether the 168 federal program claims must be refunded in full or whether some portion can be separated from her work, given that a physician interpreted each study.

2. Whether Esterline's reliance on the agency's contractual promise affects the should-have-known standard, given that the revised policy now treats such promises as insufficient.

3. Whether to disclose through the OIG self-disclosure protocol or to refund through the Medicare contractor and state Medicaid agency.

4. Whether the nine uncertain studies should be included in any refund.

5. What action to take against the agency under the staffing contract.

Actions Taken

The technologist was removed from duty on the day of confirmation. The agency was notified in writing. All other agency staff in the sleep laboratory were rescreened the same day, with no further matches. Billing for any study she worked on has been held. Records gathered in this investigation are preserved under a legal hold.

Not Decided in This Memo

This memo does not calculate a repayment amount or recommend a disclosure route. Both decisions belong to counsel and the compliance committee, and the memo is limited to the facts they need to make them.

References

Office of Inspector General. (2013). Updated special advisory bulletin on the effect of exclusion from participation in federal health care programs. U.S. Department of Health and Human Services.

Office of Inspector General. (2021). OIG health care fraud self-disclosure protocol. U.S. Department of Health and Human Services.

42 U.S.C. § 1320a-7a (2024). https://www.law.cornell.edu/uscode/text/42/1320a-7a