BUSI 311 Week 8 Discussion Board Forum 8 Example

Discussion Board Forum 8: Ethics and Compliance in Health Care Management

BUSI 311 Introduction to Healthcare Administration, Discussion Board Forum 8

Thread by [Student Name]

The practice, the health plan and the classmates are composites; the textbook, Scripture and the peer-reviewed articles cited are real.

Last month, a Medicare Advantage plan that covers about a quarter of our patients offered our practice a bonus for every in-home health risk assessment completed by its contracted nurses, along with software that suggests additional diagnoses from our charts. The plan's representative estimated it could add tens of thousands of dollars a year. I asked why the plan would pay us to find diagnoses, and the answer is risk adjustment: Medicare pays these plans more for enrollees whose recorded diagnoses predict higher costs, so every added diagnosis can raise the plan's payment for that patient for a full year.

Research shows how that incentive changes coding. Jacobs (2024) found that in-home health risk assessments and chart reviews raised Medicare Advantage enrollees' risk scores by 0.091 points, or 7.4%, in 2021, compared with what scores would have been without them. Haye et al. (2026) found that after dementia diagnoses were added back into the payment formula in 2020, new dementia diagnoses rose in Medicare Advantage relative to traditional Medicare, by 20.8% in some plan types, even as overall diagnosis rates were falling, and they note that some of the increase may reflect coding practices rather than true disease.

Buchbinder and Shanks (2017) emphasize that managers are responsible for an ethical climate and for compliance programs that prevent fraud and abuse. Recording a condition that a patient truly has, and that is being evaluated and treated, is accurate documentation. Adding diagnoses because software suggests them, without clinical evaluation, risks false claims and harms the integrity of patients' records. A diagnosis that was never really evaluated can follow a patient for years, affecting life insurance applications, future treatment decisions and even how other clinicians see them.

Our practice declined the bonus. Instead, we adopted a policy that a diagnosis is recorded only when a clinician has evaluated it and documented a plan, with a quarterly external audit of a sample of charts. We also told the plan we would welcome help with real care gaps, such as overdue screenings, which improve patients' health whether or not they change a risk score. God commanded Israel to do no wrong in measures of length, weight or quantity and to keep just balances (English Standard Version Bible, 2001/2016, Leviticus 19:35-36). A diagnosis in a chart is a measurement, and it should weigh exactly what the patient's illness weighs.

Reply to Kiara

Kiara, you described your clinic's practice of billing nurse practitioner visits under the supervising physician's name and asked whether it is ethical. It can be legal and ethical when Medicare's incident-to requirements are met, such as the physician seeing the patient first and staying involved in the plan of care, but it is easy to drift outside those requirements. Patel et al. (2022) estimated that indirectly billed nurse practitioner and physician assistant visits in Medicare nearly tripled between 2010 and 2018, reaching about 30.6 million, and that the practice was more common where state laws restricted nurse practitioners' scope. Because Medicare pays 85% of the physician rate when these clinicians bill directly, indirect billing raises payment by about 15% for the same visit. Singh et al. (2026) found that advanced practice providers are a growing share of primary care staffing, so the question will matter more each year.

Paul wrote, Pay to all what is owed to them (English Standard Version Bible, 2001/2016, Romans 13:7); that principle applies to what a clinic charges as well as what it pays. A simple safeguard is a monthly audit confirming that every incident-to claim met the rules, with training for clinicians and billing staff on what those rules require. When claims fail the audit, the clinic can bill them directly at the lower rate, which is the honest choice and removes the legal risk. Does your clinic know how many of its indirect claims would pass that audit, and who would be responsible for fixing the ones that did not?

Reply to Brandon

Brandon, you asked how a manager can make it safe for billing staff to report something that looks wrong, which may be the most important compliance question of all. Research on employee voice gives some useful direction for managers. Lainidi et al. (2023) reviewed 76 studies of voice and silence among health care workers and showed that workers' willingness to raise problems tracks the culture around them, and that speak-up campaigns achieve little where that culture is missing. Martínez (2026) argues that shared, peer-level accountability for standards, rather than blame from above, is what allows teams to correct problems before they cause harm. Together, these suggest that a hotline alone is not enough; staff need to see concerns taken seriously and reporters protected. In billing, the people who notice problems first are often coders and front-line staff with little power, so the manager's response to the first concern raised will teach everyone whether speaking up is safe.

A manager might start by thanking anyone who raises a coding question, even if the worry proves mistaken, reporting back on what was found and changed and making sure no one suffers for asking, whether through schedule changes, poor reviews or quiet exclusion. Paul urged the Ephesians to take no part in the unfruitful works of darkness, but instead to expose them (English Standard Version Bible, 2001/2016, Ephesians 5:11). Does your organization tell staff what happened after they report a concern, or do reports disappear into a compliance office without any response?

References

Buchbinder, S. B., & Shanks, N. H. (2017). Introduction to health care management (3rd ed.). Jones & Bartlett Learning.

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Haye, S., Jacobson, M., & Zissimopoulos, J. (2026). Heterogeneous responses to risk-adjustment reform: Evidence from dementia diagnosis in Medicare Advantage. Health Affairs Scholar, 4(7), qxag167. https://doi.org/10.1093/haschl/qxag167

Jacobs, P. D. (2024). In-home health risk assessments and chart reviews contribute to coding intensity in Medicare Advantage. Health Affairs, 43(7), 942-949. https://doi.org/10.1377/hlthaff.2023.01530

Lainidi, O., Jendeby, M. K., Montgomery, A., Mouratidis, C., Paitaridou, K., Cook, C., Johnson, J., & Karakasidou, E. (2023). An integrative systematic review of employee silence and voice in healthcare: What are we really measuring? Frontiers in Psychiatry, 14, 1111579. https://doi.org/10.3389/fpsyt.2023.1111579

Martínez, M. (2026). Peer accountability in patient safety: An under-examined determinant of team performance. International Journal for Quality in Health Care, 38(3), mzag134. https://doi.org/10.1093/intqhc/mzag134

Patel, S. Y., Huskamp, H. A., Frakt, A. B., Auerbach, D. I., Neprash, H. T., Barnett, M. L., James, H. O., & Mehrotra, A. (2022). Frequency of indirect billing to Medicare for nurse practitioner and physician assistant office visits. Health Affairs, 41(6), 805-813. https://doi.org/10.1377/hlthaff.2021.01968

Singh, Y., Dixit, M. N., Trivedi, A. N., & Whaley, C. M. (2026). Private equity acquisitions in primary care: Changes in utilization, spending, and workforce. Health Affairs, 45(6), 629-636. https://doi.org/10.1377/hlthaff.2025.01703