1 / 37

Case Scenarios

Case Scenarios. Now that you are familiar with the “ Frequently Used Health Care Laws ”, the DHMH Code of Conduct and the List of Probable Risk Areas , this section will walk you through various “real life” case scenarios that the DHMH OIG has investigated. Important Note:

trang
Télécharger la présentation

Case Scenarios

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Case Scenarios Now that you are familiar with the “Frequently Used Health Care Laws”, the DHMH Code of Conduct and the List of Probable Risk Areas, this section will walk you through various “real life” case scenarios that the DHMH OIG has investigated. Important Note: In order to maintain the privacy of the innocent, the names used of in the following scenarios have been changed. Click on the buttons below to view the scenarios. Each scenario consists of Issues, Investigative Techniques, Findings, Recommendations, Conclusion, and Moral. Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  2. End This Lesson Scenario #1 - Background Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  3. End This Lesson Scenario #1 - Issues Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  4. End This Lesson Scenario #1 – Investigative Techniques Investigative Techniques: Researched the pharmaceutical industry, applicable laws, and Federal websites; Reviewed KDP Provider screens, Pharmacy taxation records and pharmacy owner’s personal property records; Interview of KDP program officials; Reviewed Pharmacy’s Medicare prescriptions and the pharmacy’s records. Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  5. End This Lesson Scenario #1 – Findings Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  6. End This Lesson Scenario #1 – Recommendations Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  7. End This Lesson Scenario #1 – Conclusion Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  8. End This Lesson Scenario #1 – Moral Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  9. End This Lesson Scenario #2 - Background Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  10. End This Lesson Scenario #2 - Issues Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  11. End This Lesson Scenario #2 – Investigative Techniques Investigative Techniques: Researched the MSMHS and Just Can’t Wait to Get Paid, Inc. (budgets, funding, audited financial statements), applicable laws; Reviewed bank statements, payroll checks and associated check registers, time sheets, expense reports; Conducted interviews of staff and board members; Reviewed video tapes of items warehoused; conducted employee criminal background checks , took an inventory of equipment on hand, reviewed income tax records, etc. Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  12. End This Lesson Scenario #2 – Findings • Findings: • A recovery of approximately $20,588 was due to the Department; • Ms. Smythe’s used Department funds for various unsupported credit card purchases; • There were equipment items missing from the inventory of Just Can’t Wait To Get Paid, Inc.’s ; • Unable to discover any payroll checks having been made payable to Ms. Missy Mystery (Board President and Treasurer) as an employee; • That $20,165 had been booked as salary having been paid to employee Ms. Helpless Helper over a 4 year period. Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  13. End This Lesson Scenario #2 – Recommendations • Recommendations: • A recovery of approximately $20,588 from Just Can’t Wait to Get Paid, Inc.’s for failure to adequately document expenditures and failure retain records for five years (or until DHMH audit is completed; • Restitution of $64,015 from Ms. Smythe representing funds paid to unofficial employees of Just Can’t Wait to Get Paid, Inc.; • The case be referred to Criminal Investigations Division (CID) of the Office of the Attorney General and the Office of the State’s Attorney of Talbot County for prosecutorial review; • MSMHS strengthen operational oversight and internal controls over Just Can’t Wait to Get Paid, Inc. Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  14. End This Lesson Scenario #2 – Conclusion Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  15. End This Lesson Scenario #2 – Moral Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  16. End This Lesson Scenario #3 - Background Diverting Funds from “ Caroline County Health Department (CCHD) by an employee lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll Background: The OIG was contacted by CCHD Administrator after detecting certain accounting discrepancies discovered in the financial records of the department. The OIG conducted an audit and an investigation of the matter. During the course of the audit, the focus was directed to Mrs. Trustworthy Lightfingers, a Bookkeeper and Administrative Assistant at CCHD. Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  17. End This Lesson Scenario #3 - Issues Diverting Funds from “ Caroline County Health Department (CCHD) by an employee lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll Background: The OIG was contacted by CCHD Administrator after detecting certain accounting discrepancies discovered in the financial records of the department. The OIG conducted an audit and an investigation of the matter. During the course of the audit, the focus was directed to Mrs. Trustworthy Lightfingers, a Bookkeeper and Administrative Assistant at CCHD. Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  18. End This Lesson Scenario #3 – Investigative Techniques Diverting Funds from “ Caroline County Health Department (CCHD) by an employee lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll Background: The OIG was contacted by CCHD Administrator after detecting certain accounting discrepancies discovered in the financial records of the department. The OIG conducted an audit and an investigation of the matter. During the course of the audit, the focus was directed to Mrs. Trustworthy Lightfingers, a Bookkeeper and Administrative Assistant at CCHD. • Investigative Techniques: • Auditing the CCHD (Including a review of the related budgets, program receipts and disbursements), bank statements and slips of deposit, general and subsidiary ledgers, including CCHD’s “One Write Accounting System”; • Interviewed Mrs. Lightfingers, other CCHD staff as well as the Bank’s top tier management staff, and • Conducted employee criminal background checks. Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  19. End This Lesson Scenario #3 – Findings Diverting Funds from “ Caroline County Health Department (CCHD) by an employee lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll Background: The OIG was contacted by CCHD Administrator after detecting certain accounting discrepancies discovered in the financial records of the department. The OIG conducted an audit and an investigation of the matter. During the course of the audit, the focus was directed to Mrs. Trustworthy Lightfingers, a Bookkeeper and Administrative Assistant at CCHD. • Findings: • Cash was missing from the CCHD • deposits $35,737 in total (representing 101 • of the 149 tested days; • When cash was missing, daily • deposits were balanced using other • sources; • The cash receipts One-Write-System • had been falsified to conceal the cash • loss; • Cash losses began before July, 1, 2001 • and ended on February 28, 2005; • Mrs. Trustworthy Lightfingers began • her Administrative leave on March 4,2005; • For thirteen (13) days of deposits • tested when Mrs. Lightfingers was on • leave, the audit detected no shortages; • Mrs. Lightfingers later resigned from • the Department. Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  20. End This Lesson Scenario #3 – Recommendations Diverting Funds from “ Caroline County Health Department (CCHD) by an employee lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll Background: The OIG was contacted by CCHD Administrator after detecting certain accounting discrepancies discovered in the financial records of the department. The OIG conducted an audit and an investigation of the matter. During the course of the audit, the focus was directed to Mrs. Trustworthy Lightfingers, a Bookkeeper and Administrative Assistant at CCHD. Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  21. End This Lesson Scenario #3 – Conclusion Diverting Funds from “ Caroline County Health Department (CCHD) by an employee lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll Background: The OIG was contacted by CCHD Administrator after detecting certain accounting discrepancies discovered in the financial records of the department. The OIG conducted an audit and an investigation of the matter. During the course of the audit, the focus was directed to Mrs. Trustworthy Lightfingers, a Bookkeeper and Administrative Assistant at CCHD. Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  22. End This Lesson Scenario #3 – Moral Diverting Funds from “ Caroline County Health Department (CCHD) by an employee lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll Background: The OIG was contacted by CCHD Administrator after detecting certain accounting discrepancies discovered in the financial records of the department. The OIG conducted an audit and an investigation of the matter. During the course of the audit, the focus was directed to Mrs. Trustworthy Lightfingers, a Bookkeeper and Administrative Assistant at CCHD. Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  23. End This Lesson Scenario #4 - Background Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  24. End This Lesson Scenario #4 - Issues Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  25. End This Lesson Scenario #4 – Investigative Techniques • Investigative techniques: • A review of COMAR Title 17, DHMH Tuition Reimbursement Program Guidelines for 20/20 Work Release Program; • A review of Ms. Neverthere’s work-study schedule approved by DHMH and Ms. Neverthere’s Obligated Service Agreement with DHMH (dated 3/29/06); • Ms. Neverthere’s timesheets for the period 6/7/06 – 8/14/07; • WPCC’s internal memoranda regarding Ms. Neverthere’s participation in the 20/20 work release program; • WPCC’s 11/1/07 letter of separation for Ms. Neverthere’s release from employment. Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  26. End This Lesson Scenario #4 – Findings Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  27. End This Lesson Scenario #4 – Recommendations Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  28. End This Lesson Scenario #4 – Conclusion Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  29. End This Lesson Scenario #4 – Moral Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  30. End This Lesson Scenario #5 - Background Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  31. End This Lesson Scenario #5 - Issues Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  32. End This Lesson Scenario #5 – Investigative Techniques Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  33. End This Lesson Scenario #5 – Findings Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  34. End This Lesson Scenario #5 – Recommendations Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  35. End This Lesson Scenario #5 – Conclusion Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  36. End This Lesson Scenario #5 – Moral Issues Investigative Techniques Findings Recommendations Conclusion Moral Scenario #1 Scenario #2 Scenario #3 Scenario #4 Scenario #5

  37. Violation of Procurement and Ethics laws by a Health Officer • Background: • Mr. Smith was the Health Officer with one of • DHMH’s County Health Departments. The • County Commissioners had overriding • authority over Mr. Smith’s employment with • support from the State. • The OIG received a complaint from Trust • Transport Services (TTS). TTS was the • vendor awarded the Medicaid funded • transportation contract for Mr. Smith’s County • Health Department. In the TTS complaint, it • was reported that Mr. Smith terminated • TTS’s contract and awarded it to We Gotcha • Transportation Services (WGTS) without • undergoing the official procurement • procedures. • The Inspector General met with the • proprietors of TTS, and were informed that • Mr. Smith served on the Board of Directors of • “All Wise Health System, Inc., of which the • WGTS was an affiliate. • Following the initial meeting with TTS, the • Inspector General met with Mr. Smith, other • Health Department staff, collected • evidentiary matter, met with internal and • external partners in order to ascertain the • validity of the newly awarded contract. • During the investigation, the OIG discovered • that the DHMH Internal Audit Unit had • recently conducted an audit of the County • Health Department. The audit report • indicated: • Medical transportation contract for the period reviewed were not handled by the DHMH Procurement Department, but by a Chief Administrator within the County Health Department; • The new contract award to WGTS had not been signed by a representative of the County Commissioners; • There was no evidence that the contract had been competitively bid; • The County Health Department had received notice in 2003 and 2004 from the DHMH Internal Auditors of the competitive bidding requirements used to award Medicaid funded transportation services contracts. • Investigative techniques: • A review of COMAR Title 17, DHMH Tuition Reimbursement Program Guidelines for 20/20 Work Release Program; • A review of Ms. Neverthere’s work-study schedule approved by DHMH and Ms. Neverthere’s Obligated Service Agreement with DHMH (dated 3/29/06); • Ms. Neverthere’s timesheets for the period 6/7/06 – 8/14/07, • WPCC’s internal memoranda regarding Ms. Neverthere’s participation in the 20/20 work release program; • WPCC’s 11/1/07 letter of separation for Ms. Neverthere’s release from employment.

More Related