Root Cause Analysis: Fraud Case
Throughout this course, you have examined occurrences of the types of health care noncompliance, fraud, and abuse that commonly take place in the context of the regulatory environment in which organizations must operate. To ensure the best chance of avoiding intentional and unintentional noncompliance, health care administrators should devise and adopt a risk management plan that identifies, assesses, and analyzes the risks and tolerances inherent in the organizations’ processes and operations.
One of the crucial aspects of risk management involves strategies for actions that should be taken in the event of a violation or breach of any nature. These mitigating actions should be followed up with remediation aimed at finding the causes leading up to the incident. This is where root cause analysis comes into the picture.
Root cause analysis is a structured, retrospective analysis of events leading up to the noncompliant event. By developing an organization-wide policy for conducting root cause analyses that is adaptable to specific operations, a cause might be determined, and preventive actions and solutions developed.
In this assessment, you examine a case of fraud and try to determine why and how it happened.
Read “Maryland Health Care Provider Sentenced to 10 years in Federal Prison for Health Care Fraud Resulting in Patient Deaths” from the United States Attorney’s Office.
Use the Five Whys to conduct a root cause analysis to determine why the Medicare fraud occurred and Timothy Emeigh’s participation in the case. Write a 700- to 1050-word analysis that identifies and evaluates the root cause for Medicare fraud in this case.
Include the following:
Articulate the Five Whys for this case and provide an explanation for each.
Speculate how and why Mr. Emeigh participated in the scheme.
Explain what you, as an administrator, might have done to prevent this from happening.
Recommend risk management strategies the organization can utilize to prevent this and similar types of events from occurring in the future.
Cite your sources according to APA guidelines.
Root Cause Analysis
Name
Institution
Course
Instructor
Date
Root Cause Analysis
The problem
Medical care provider Condemned to 10 years in Government Jail.
Why
The care provider caused the death of the patients
Why
He stole the identity and falsified statements of qualified doctors
Why
Medicare and Medicaid covered the patients, and The caregivers wanted money from medical insurance companies.
Why
The company's employees were willing and cooperative toward the scheme.
Why
The healthcare provider was not qualified as a physician.
The healthcare provider was not qualified.
Rafael Chikvashvilli holds a Ph.D. in mathematics and has never been a licensed physician or a medical doctor. However, he started Alpha Diagnostic, which provided healthcare services like ultrasound and X-ray (Justice.gov, 2016). He also became the executive director of the corporation. The cooperation of employees aided Rafael in succeeding in the crime of fraud.
The employees were willing and cooperative.
Based on the evidence, Rafael did not solely carry out the crime alone. Emeight (the vice president of Alpha Diagnostics) and other non-physicians interpreted X-rays, work that a licensed radiologist should have done (Justice.gov, 2016). Emeight was a radiologic technologist, yet he was willing to carry out the functions of radiologists. Moreover, Emeight did not decline Rafael's instruction to view medical images through a laptop and draft false interpretations.
Medicare and Medicaid covered patients.