Root Cause Using 5 Whys Case Study
ANSWER
Case: A Maryland healthcare provider who committed fraud that caused patient deaths was sentenced.
First, why: What caused Medicare fraud?
As a result of the healthcare provider overcharging and filing false claims for medical services that were never rendered to patients, Medicare fraud took place.
Second reason: What motivated the healthcare practitioner to submit inflated invoices and misleading claims?
Due to decreased income and rising operating expenses, the healthcare provider needed financial help. Due to the financial strain, they turned to fraudulent activities to increase their revenue.
Third Reason: What brought about the healthcare provider’s financial challenges?
Response: Several causes, including decreased Medicare reimbursement rates, greater competition from other healthcare providers, and improper financial resource management, contributed to the healthcare provider’s financial difficulties.
The fourth reason is: Why did Medicare lower reimbursement rates?
Response: Due to tight financial restrictions and the need to preserve the longevity of the Medicare program, Medicare reduced reimbursement rates as part of cost-cutting efforts.
The healthcare provider mismanaged financial resources, which brings us to our fifth why.
The healthcare provider squandered financial resources because of poor financial management procedures, improper monitoring, and perhaps a lack of financial management training inside the company.
Timothy Emeigh’s Participation: Several things could have led Timothy Emeigh to participate in the scam. He probably felt pressured to commit fraud by the management of the healthcare provider in order to increase profits. His involvement might have been motivated by personal financial issues or ambitions for money. It is also likely that he justified his participation to ensure the healthcare provider’s financial existence, even if doing so required engaging in unlawful acts.
Prevention: Several steps could be taken to avoid a situation like this:
Improved Oversight: Set up better internal controls to monitor business operations to spot and stop fraud. Finding abnormalities can be aided by routine audits and analyses of financial transactions.
Ethics Instruction: Provide ethics instruction to all staff members, stressing the need for honesty and legal observance. This may contribute to the development of an ethical culture within the company.
Financial Education: Provide staff members who work with money with financial management training. This can lessen the desire to engage in fraudulent operations and prevent resource mismanagement.
References: Please be aware that I am unable to access outside sources; however, you can look up trustworthy references on Medicare rules, health care fraud, and the 5 Whys method through sources including official websites, scholarly journals, and business periodicals.
QUESTION
Description
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.
Include the following:
List each of the 5 Whys and your response.
Speculate as to why Mr. Emeigh participated in the scheme.
Explain what you might have done to prevent this from happening.
- Cite 3 reputable references to support your assignment (e.g., trade or industry publications, government or agency websites, scholarly works, or other sources of similar quality).
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