Root Cause Analysis

Irregular Billing of Medical Insurers Comprehensive Nursing Essay Example

The U.S. government has established measures for dealing with fraudulent activities involving irregular billing of medical insurers. The case under analysis involves Medicare insurance claims at Alpha Diagnostics, which resulted in the deaths of two patients (U.S. Attorney’s Office, 2016). The paper analyzes the source of Medicare fraud at the health facility using the Five Whys technique. It will also speculate on the factors which drove Mr. Emeigh into engaging in the fraudulent activities, including identifying measures an administrator could have implemented to prevent the fraud. The last part will recommend risk management strategies that healthcare organizations can utilize to prevent fraud. Therefore, healthcare organizations should implement effective fraud control strategies to prevent fraud which commonly occurs through various activities like billing and medical identity theft.(Irregular Billing of Medical Insurers Comprehensive Nursing Essay Example)

The Five Whys Analysis for the Case

The Five Whys analysis refers to the procedure used in problem identification to determine the source of a problem and its effects (Okes, 2019). It identifies challenges and helps in developing solutions to problems. The technique can be used to determine the cause and effect of the fraud involving Rafael Chikvashvili at Maryland health care Centre. For instance, why was Mr. Chikvashili charged with fraud? Mr. Chikvashili was found guilty of fraud due to various irregular activities at the health facility, such as falsifying cardiologic and ultrasound reports (U.S. Attorney’s Office, 2016). Other fraudulent activities include submitting insurance claims for operations that were not performed and lying that licensed radiologists interpreted the ultrasound and cardiologic reports.(Irregular Billing of Medical Insurers Comprehensive Nursing Essay Example)

Besides, why was the problem not detected earlier? The Medicare database is not designed to effectively detect fraudulent activities, making it easy for criminals to defraud the health insurer. Also, why did the two patients die? The patients died due to the failure of a qualified radiologist to review their x-ray results (U.S. Attorney’s Office, 2016). The results were reviewed and interpreted by non-physician employees, resulting in medical errors.(Irregular Billing of Medical Insurers Comprehensive Nursing Essay Example)

Additionally, why did the unqualified physicians review the results? These physicians, including Emeigh, were acting under the orders of Mr. Chikvashili, the owner of Alpha Diagnostics (U.S. Attorney’s Office, 2016). Finally, why did the health facility perform x-rays and cardiologic examinations without a licensed radiologist? This could be due to the ineffective implementation of background check policies for monitoring and ensuring that healthcare facilities comply with the licensure regulations.(Irregular Billing of Medical Insurers Comprehensive Nursing Essay Example)

Speculate how and why Mr. Emeigh participated in the Scheme

            Mr. Emeigh participated in the scheme by failing to report the fraudulent activities to the relevant authorities. Also, agreeing to interpret x-rays and perform cardiologic examinations with an expired license is considered a crime. The radiologist’s license expired in 2015 and was also not a licensed medical practitioner. Besides, Mr. Emeigh conspired with Mr. Chikvashli to falsify physician reports and signatures (U.S. Attorney’s Office, 2016). Message conversations between them prove this. Notably, U.S. Attorney’s Office (2016) reports that Mr. Emeigh participated in the scheme by acting on the instructions of Mr. Chikvashli. Witness testimonies revealed that Mr. Chikvashli forced Alpha Diagnostics’ employees, including Mr. Emeigh, to draft falsified physician reports in insurance claims.(Irregular Billing of Medical Insurers Comprehensive Nursing Essay Example)

What an Administrator might have done to Prevent the Fraud

A healthcare facility administrator is crucial in overseeing and ensuring smooth operations. To effectively perform this role and prevent fraudulent activities, an administrator would have implemented effective measures for supervising and evaluating the activities of the hospital’s staff (Ekin, 2019). Also, planning and implementing fraud prevention programs like regular auditing by external parties could have identified and prevented the fraud earlier. Additionally, the administrator should have maintained constant communication with the hospital staff by conducting regular meetings (Ekin, 2019). This could have prevented fraud since such meetings can provide ample opportunities for the staff to raise concerns about their activities. Caliyurt (2018) observes that an administrator is responsible for coordinating financial reporting, accounting, and other fiscal operations. In this context, competent performance of these duties would have helped detect irregular financial transactions based on falsified insurance claims.(Irregular Billing of Medical Insurers Comprehensive Nursing Essay Example)

Risk Management Strategies

There are various risk management strategies the health care organization could implement to prevent fraud. They include hiring external auditors for regular auditing of the hospital’s activities is critical in detecting mishaps in its accounts and other operations. Additionally, establishing and regularly revising the internal control reports is vital to fraud prevention (Caliyurt, 2018). Internal control programs are essential in safeguarding and improving the integrity of the hospital’s accounts and activities, which are essential in deterring fraud. They can also include segregation of duties among the hospital staff, making it challenging for top management to engage in fraudulent activities (Ekin, 2019). Also, Stowell, Schmidt, and Wadlinger (2018) explain that establishing fraud reporting systems makes it easy for employees and clients to report irregular workplace occurrences anonymously. A reporting system that guards the privacy of fraud reporters would help some hospital staff may be honest and unwilling to participate in fraudulent activities but are also not ready to lose their jobs for reporting such activities.(Irregular Billing of Medical Insurers Comprehensive Nursing Essay Example)

Conclusion

Medical billing and identity theft are common ways healthcare staff commit fraud, calling for establishing effective prevention mechanisms in these organizations. The five ways utilized in the analysis explored the root cause of Medicare fraud at Alpha Diagnostics by formulating questions such as why Mr. Chikvashili was charged with fraud and why the two patients died. The analysis also found that Mr. Emeigh engaged in the scheme by falsifying physician reports under the instructions of Mr. Chikvashli. In this context, an administrator would have prevented fraud by implementing prevention programs and maintaining constant communication with hospital staff. Also, essential risk management strategies that could be implemented to prevent fraud in such organizations include establishing internal controls and regular auditing of the activities within the organization. Henceforth, dealing with Medicare fraud is essential in streamlining hospital operations and improving patient outcomes.(Irregular Billing of Medical Insurers Comprehensive Nursing Essay Example)

References

Caliyurt, K. T. (2018). Fraud Prevention in Health Sector: Proposals of Solution. Available at SSRN 3121738. (Irregular Billing of Medical Insurers Comprehensive Nursing Essay Example)DOI:10.2139/ssrn.3121738

Ekin, T. (2019). Statistics and health care fraud: How to save billions. New York: Chapman and Hall/CRC. DOIhttps://doi.org/10.1201/9781315278254

Okes, D. (2019). Root cause analysis: The core of problem-solving and corrective action. (2nd ed.). Milwaukee, Wisconsin: Quality Press. (Irregular Billing of Medical Insurers Comprehensive Nursing Essay Example)ISBN: 9780873899826

Stowell, N. F., Schmidt, M., & Wadlinger, N. (2018). Healthcare fraud under the microscope: improving its prevention. Journal of Financial Crime(Irregular Billing of Medical Insurers Comprehensive Nursing Essay Example). ISSN: 1359-0790

U.S. Attorney’s Office (2016, June 15). Maryland Health Care Provider Sentenced to 10 Years in Federal Prison for Health Care Fraud Resulting in Patient Deaths(Irregular Billing of Medical Insurers Comprehensive Nursing Essay Example). [Press release]. https://www.justice.gov/usao-md/pr/maryland-health-care-provider-sentenced-10-years-federal-prison-health-care-fraud