Health Care Fraud Case Study
Organizational Responsibility
Organizational structure and culture influence have a huge effect on the success or downfall of an organization. Many organizations have proper processes in place to prevent health care fraud and abuse. This paper reviews fraud and abuse and how organizational structure and governance, culture, and focus on social responsibility affect or influenced the described situation. This paper will also review resources and allocation to prevent this type situation in the future, and the ethical issues that may relate to the determination of the described solution. Additionally, this paper will provide recommendations for structure or culture changes necessary to prevent this situation in the future.
Health Care Fraud A clinic for outpatient psychiatric for mentally ill senior citizens in a low income urban area was charged with health care fraud, and an investigation was ordered. The allegations included several psychiatrists who would arrive at the clinic, and simply ask a nurse on duty how the patients were doing and chart psychotherapy notes, and bill Medicare for 50 minutes of sessions. Approximately one third of the claims submitted to Medicare were upcoded, and the clinic was billing for each service individually as …show more content…
A medical supplier was found guilty of five counts of health care fraud and sentenced to 120 months incarceration and restitution of $1.6 million. Raritan Bay Medical Center paid $7.5 million to settle a Medicare fraud charges, AmeriGroup Illinois, Inc. was charged with refusing to register pregnant women. A dermatologist in Florida was sentenced to 22 years in prison and paid $3.7 million in restitution for performing medically unnecessary surgeries on 865 Medicare patients (Rudman, 2009, para. 1-4). Such examples clearly demonstrate that fraud and abuse rigorously occur, and present a huge expenditure for the health care
Organizational structure and culture influence have a huge effect on the success or downfall of an organization. Many organizations have proper processes in place to prevent health care fraud and abuse. This paper reviews fraud and abuse and how organizational structure and governance, culture, and focus on social responsibility affect or influenced the described situation. This paper will also review resources and allocation to prevent this type situation in the future, and the ethical issues that may relate to the determination of the described solution. Additionally, this paper will provide recommendations for structure or culture changes necessary to prevent this situation in the future.
Health Care Fraud A clinic for outpatient psychiatric for mentally ill senior citizens in a low income urban area was charged with health care fraud, and an investigation was ordered. The allegations included several psychiatrists who would arrive at the clinic, and simply ask a nurse on duty how the patients were doing and chart psychotherapy notes, and bill Medicare for 50 minutes of sessions. Approximately one third of the claims submitted to Medicare were upcoded, and the clinic was billing for each service individually as …show more content…
A medical supplier was found guilty of five counts of health care fraud and sentenced to 120 months incarceration and restitution of $1.6 million. Raritan Bay Medical Center paid $7.5 million to settle a Medicare fraud charges, AmeriGroup Illinois, Inc. was charged with refusing to register pregnant women. A dermatologist in Florida was sentenced to 22 years in prison and paid $3.7 million in restitution for performing medically unnecessary surgeries on 865 Medicare patients (Rudman, 2009, para. 1-4). Such examples clearly demonstrate that fraud and abuse rigorously occur, and present a huge expenditure for the health care