Organizational Responsibility and Current Health Care Issues - Term Paper Example

? Running head: Health Sciences and Medicine Organizational Responsibility and Current Health Care Issues Insert Insert Grade Insert ’s Name 30 May 3012 Background Healthcare fraud would be described as a deliberate misrepresentation of fact targeted to benefit the interest of someone at the expense of the public, unfairly, and usually perpetrated by avoiding protocol procedures in healthcare subsector or elsewhere hence unauthorized. Abuse in healthcare, on the other hand, involves unnecessarily charging for non-medical services (or products), which may sometimes be over or under priced and in total disregard of the established professional standards to achieve certain personal objectives. The result of these unprofessional and criminal practices is an ailing health sector, poor health care standards, and reduced impact of government’s efforts in terms of provision of resources for the public health care services. In the United States, there have been a number of cases of fraud and abuse in the healthcare sub sector, but Federal authorities have unearthed and prosecuted many of these since early 1990’s; recovering substantial financial resources, as a result. Fraud can be a cause of significant losses in the public health sector denying the people efficient and most wanted medical services, which has repercussions of compromising the effective achievement of public health goals in a country. The practice can be curtailed through studying how it is originated and executed. This paper will explore the crime of healthcare fraud and abuse focusing on the effect of the organizational structure and governance, culture, and social responsibility and making recommendations on how these can be balanced to ensure the reduction of the vice or/and its complete elimination. The paper will also make evaluation of the sources that may be required to be allocated to avert future recurrence. In addition, it will assess the ethical issues that relate to the decision of allocating resources to combat it. Organizational Structure and Governance, Culture, and Social Responsibility and Health Care Fraud and Abuse a. A case of a health care news situation affecting a medical related organization A case in point of fraud and abuse of financial resources in a public hospital, for example, is one reported by the Kaiser Health News (KHN) where the Connecticut House passed a budget short by about $ 50 million in Medicaid programs because of medical fraud. It was alleged that doctors from Parkland Memorial Hospital and UT Southwestern medical Centre took advantage of the federal government’s health insurance programs. This was to the detriment of ageing and the underprivileged. Moreover, a lot of Medicare or Medicaid billing claims were falsely made with the intention to defraud the government medical fund through rehabilitation consultations. Medicaid costs had gradually risen to surpass costs of Medicare program for seniors or even private sector employer-sponsored plans in the last decade (KHN, 2012, p. 1). This raised more eyebrows and called for investigations after a federal judge spilled the beans through unsealing a whistle-blower lawsuit. b. Influence of the organizational structure and governance, culture and social responsibility on Fraud in Health care set up Fraud has the capability of destroying the reputation or image of any organization such as a hospital, insurance company, government agency or even a clinic for that matter as some of the institutions identified for this study. It can create fear, mistrust, insolvency and poor financial performance for an organization. Studies have shown that fraud contributes a minimum of 6% of any organization’s revenue or cash flow losses. The vice occurs during the normal hours of business operations and involves bending or/and breaking rules and regulations as well as going around internal control systems and financial reporting standards as an insider job, usually with the organization’s employees. Areas of operations, where fraud thrives, include front office activities like billing, middle and back office activities such as reconciliations and payments, book keeping including general ledger, tax accounting among many others. Other avenues through which fraud in med services happens is through misrepresentation of facts in terms of what was offered, conditions and charges involved as well as details of the provider recipient. Carrying out unnecessary services or medical tests may be another way of benefiting from undeserved claims unfairly through fraud. Still, fraud can be achieved through forms such as miscoding, kickbacks, up coding, double charging and unbundling of claims (Agency Group, 2010, p. 20). Organization structure and governance in a hospital, for example, has influence on the amount of fraud that can occur. First, a structure that does not comprise the right and appropriate supervisory hierarchy1 may be a candidate for increased fraud activities especially if the persons heading the different levels do not have the professional discipline and integrity needed to achieve transparency, accountability and freedom of public scrutiny. The cultural orientation in an organization can also influence or affect the fraud and abuse. If the culture does not embrace integrity and accountability, then the degree of abuse of financial resources will be higher because operational norm allows bending rules and regulations, non-adherence to standards and deliberately encourages misuse of public funds for the benefit of few. Modern management styles will yield to a positive culture, one that embraces all the good things that contribute to the achievement of organizational goals. Corporate social responsibility (CSR) is an initiative where corporate or public organizations contribute to the improvement of social and economic wellbeing by giving back to the society through activities that aim to sustain the environment, build infrastructure, improve health and lifestyle standards, encourage ethical culture and tradition, and enhance social integration. Where people are involved in the health sector programs, the probability that fraud and abuse takes place may be minimized. Still, it may be argued that funds used to undertake CSR programs may otherwise have been misappropriated through fraud and the society ends up benefiting in place of a few individuals (Agency Group, 2010, p.25). c. Resource Allocation And Related Ethical Issues In Health Sector Fraud Financial, human, and time resources may be beneficial in dealing with fraud. Governments usually put in place well-funded agencies such as anticorruption bodies with full human expertise and equipment necessary for dealing with the problem. The legislative process must also provide for how cases of medical fraud or indeed any other fraud may be handled. Many medical related frauds can be unearthed by probing insurance payment reports. This will help ascertain whether they indeed accurately reflect the services purported to have been delivered. If a private insurer is making suspicious claims, the same should be reported to the company's fraud department as soon it is practical. In the USA, the government makes public the sanction list2, which contains names of individuals and entities excluded from federal programs. The OIG3 has provided a hotline for anyone to report suspicious practices in Medicare or other federal programs. In fact, the OIG (in order to reduce instances of medical and healthcare fraud) bans funding by the federal government for any bills submitted for services or items furnished or provided upon medical prescription by an entity or individual excluded under the two list systems. Strict penalties are in place in case this policy provisions are not adhered to, including but not limited to civil monetary penalties and corporate integrity agreements. Ethical issues or challenges that may be related to the decision to employ resources to curb fraud include social and organizational culture, practices or influences such as kickbacks, bribes, favoritism, nepotism, romance, conflicts of interest, harassment, prejudice, as well as discrimination. Another ethical issue hospitals face in relation to the environment is the determination of the most effective and cheaper ways of disposal of waste particularly the bio-hazardous waste. Patient confidentiality as an ethical issue has both the health and a business perspective. Some firms will offer to pay the hospital to get certain personal data for customers, and the hospice must stand its ground and uplift professional standards. Hospitals should ensure maximum use of resources like machines and equipment even under unwarranted circumstances (Kieke, 2001, p. 48). The setting of prices and fees by doctors and hospitals is also an ethical issue because it is business driven at the expense of the patients. To secure medically-necessary-treatment for patients, some doctors usually will report misleading diagnoses that again raises certain ethical issues. d. How to change the structure, governance, culture, or focus on social responsibility to prevent Health sector fraud To effectively deal with fraud and abuse in an organization in a healthcare setup, a number of solutions may be suggested. The organizational structure should be such that it allows growth of a positive and professional culture for individuals to embrace and practice bioethics. Usually, if organizational ethics are upright, the individuals’ bioethics by the practitioners will be in order. The organization should employ people with integrity and sustain a positive culture through continued training, regular personality checks and auditing the work of its employees. An organization should conduct a check of all existing employees and suppliers to ensure there are no payments done to ghost entities or individuals and no unethical practices are in place (Kieke, 2001, p. 48). The management must ensure that the organization’s vision, goals and strategies are known to everyone; clear operational procedures and internal controls are in place and subjected to regular audits with the mandatory requirement for comprehensive reporting to uphold account ability and responsibility. The culture of integrity and transparency will then be created as an outcome of observance of these procedures. Every public or private entity must engage in social responsibility activities as a way of sharing resources with the public to uplift the social good and to open institutions to public scrutiny to promote organizational responsibility. CSR initiatives also have economic and ethical gains to society. References Agency Group, (2010). A Zero-Tolerance Approach to Health Care Fraud. FDCH Regulatory Intelligence Database. KHN, (2012). DOJ Probes Fraud AT Parkland Hospital; Texas Group Calls Medicaid ‘Indispensable’. Retrieved from Kieke, R. (2001). Hospitals Step Up Efforts to Screen Employees and Vendors. Journal of Health Care Compliance, Vol. 3 Issue 3, p48. Read More