Root Cause Analysis

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 organization’s 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 will 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 5 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 1,050-word analysis that identifies and evaluates the root cause for Medicare fraud in this case. Include the following: • Explain the “5 Whys” for this case. • 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 use to prevent this and similar types of events from occurring in the future. Cite your sources according to APA guidelines.

Answer

Root Cause Analysis

The 2016 case involving the owner of Alpha Diagnostics, Rafael Chikvashvili provides an ideal scenario of the consequences of healthcare fraud, especially the violation of the False Claim Act that prohibits care providers from fraudulently billing for unprovided services to acquire financial gains from Medicare and Medicaid programs. According to Mackey et al. (2020), healthcare fraud and Abuse results in an estimated $2.6 billion in financial loss. As revealed in the case, healthcare fraud and abuse amount to civil (monetary) penalties and legal changes, including imprisonment of the perpetrators. Therefore, this paper elaborates on the fraud case by applying the “5 Whys” of root cause analysis and recommending risk management strategies to prevent future occurrences of such fraudulent activities.

The “5 Whys” of Root Cause Analysis

Why did the court convict Rafael Chikvashvili?

The US District Judge James K. Bredar sentenced Rafael Chikvashvili to 10 years in prison because of two major reasons: failing to provide medical services to patients and billing for services that he did not provide. For instance, the court revealed that he conspired with other employees to defraud Medicare and Medicaid by creating false radiology, ultrasound, and cardiology interpretation reports. Also, Chikvashvili submitted insurance claims for medical interpretations completed by unlicensed physicians. These activities led to the death of two patients.

Why did the patients die?

The patients died due to a lack of access to quality and convenient care. For instance, non-physician Alpha Diagnostics employees failed to detect patients’ underlying health conditions, including congestive heart failure. Instead, the organization transferred the patients to a rehabilitative nursing home. The subsequent failure to detect congestive heart failure and incorrect reading of the patient’s chest X-ray exacerbated the risk of bleeding during and after surgery. These factors led to the patient’s death.

Why did the court sentence Emeigh?

Timothy Emeigh was among Alpha Diagnostics employees who participated in the scheme to defraud Medicare and Medicaid. In this sense, he implemented instructions by Chikvashvili to interpret X-rays, ultrasounds, and cardiologic examinations instead of licensed radiologists. The evidence showed that Chikvashvili directed Emeigh through telephone calls and text messages to draft false physician interpretation reports by viewing medical images using his laptop. These incidences justified the court’s decision to sentence Emeigh.

Why did Chikvashvili involve Medicare and Medicaid in the fraudulent act?

Chikvashvili’s targeted to receive more than $6 million reimbursement from Medicare and Medicaid through fraudulent activities. Therefore, he collaborated with other employees to submit false claims to Medicare and Medicaid for services that they did not provide. Also, they fraudulently obtained medical interpretation reports by opting for non-physicians to justify their false claims. By applying these deceptive strategies, Chikvashvili and Alpha Diagnostics received more than $6 million from Medicare and Medicaid.

Why did Alpha Diagnostics fail to provide quality medical care to the patients?

Chikvashvili and Alpha Diagnostics failed to provide quality care to patients by failing to detect health issues like congestive heart failure by misinterpreting chest X-rays. Also, Chikvashvili conspired with non-physicians like Emeigh to draft false medical reports and insurance claims to fraudulently obtain reimbursement from Medicare and Medicaid. These activities amounted to unprofessionalism and negligence, leading to patients’ death.

Speculating how and why Emeigh participated in the scheme

Two broad hypotheses can speculate Emeigh’s involvement in the scheme to defraud Medicare and Medicaid. Firstly, Chikvashvili may have threatened and used his authority and position to coerce Emeigh to conspire to fraudulently obtain reimbursement from Medicare and Medicaid. Secondly, Chikvashvili may have promised him some kickbacks after participating in the conspiracy. In this sense, Emeigh anticipated financial gains as compensation for participating in the scheme. This premise violates the Anti-Kickback Law.

What I might have done to prevent the incident

As an administrator for Alpha Diagnostics, I would have detected the incident by requiring an audit committee to conduct comprehensive and periodic audits to detect any anomalies or fraudulent entries for insurance claims and billings. Also, I would have used an integrated data repository and computer-aided auditing systems to detect excessive claims, fraud, and abuse. Another option for preventing the incident is requiring every practitioner to perform self-audits and report any overpayments received from the government health programs, where the failure to adhere to this provision would be subject to prosecution.

Risk Management Strategies to Prevent Future Healthcare Fraud and Abuse

The organization should implement effective interventions for preventing future occurrences of similar types of fraudulent activities. These strategies include incentivizing timely and proper incident reporting by whistleblower protection and incorporating blockchain into software architecture to ensure effective data management (Mackey et al., 2020). On the other hand, Che et al. (2020) support the development of a comprehensive compliance program by educating employees about due diligence, using integrated data repository and data mining tools to detect anomalous and excessive claims, and applying computer-aided auditing to curb drug diversion and other fraudulent activities. These interventions can prevent future occurrences of healthcare fraud and avert the adverse consequences of healthcare fraud and abuse.

References

Chen, Z. X., Hohmann, L., Banjara, B., Zhao, Y., Diggs, K., & Westrick, S. C. (2020). Recommendations to protect patients and health care practices from Medicare and Medicaid fraud. Journal of the American Pharmacists Association, 60(6), e60–e65. https://doi.org/10.1016/j.japh.2020.05.011

Mackey, T. K., Miyachi, K., Fung, D., Qian, S., & Short, J. (2020). Combating health care fraud and abuse: Conceptualization and prototyping study of a blockchain antifraud framework. Journal of Medical Internet Research, 22(9), e18623. https://doi.org/10.2196/18623

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