Health Care Fraud

Topics: Health care, Health economics, Medicine Pages: 9 (1474 words) Published: December 5, 2014

Organizational Responsibility and Current Health Care Issues Paper - Health Care Fraud Roberta Roelofs
HCS / 545
November 17, 2014
Michael Grossman

Health care fraud is a current health care issue throughout the health care industry from hospitals to home care services. “The National Health Care Anti-Fraud Association (NHCAA) estimates that health care fraud accounts for at least three, but as much as ten percent of total health care expenditures”(Hubbell, 2006). Health care organizations that work with medicare and medicaid are at higher risk for being a target for health care fraud. Many organizations have abused the use of the money system with billing illegal charges to insurance companies to allow for themselves to make more money over the years.

Professional Medical Home Health is a home health care company that has been accused of health care fraud with medicare. The organizational structure of the company, culture, ethics, and the lack of focus on a social responsibility to the patients, had an affect or influenced the situation of health care fraud and abuse. The government is working with changes to help with ethical issues to help with implementing resources to help prevent health care fraud from happening in the future of the companies. Changes to the organizational structure of the company, culture, and the lack of focus on the social responsibility to the patients can also help with the prevention of health care fraud. Health Care News Situation

Professional Medical Home Health is a home health care company that has been charged with alleged participation in a $6.2 million Medicare fraud scheme. During the Medicare scheme “the defendants solicited and received kickbacks from the owners and operators of Professional Home Health in exchange for providing beneficiaries for home health services that were not medically necessary or not provided” (, 2014). Along with the soliciting and receiving the kickbacks, the defendants also falsified documentation to support the fraudulent billing. These charges happened between the time of December 2008 and February 2014. The owner and administrator of Professional Medical Home Health have pleaded guilty of the charges for committing health care fraud with false statements related to health care matters. During this time of December 2008 and February 2014, claims were made that services were provided for home health care services and therapy services to Medicare. Unfortunately patient information was falsified with in fact that some of the individuals never did qualify or receive such services from this company. The Influences of Organizational Structure and Governance

Each health care organization has many layers no matter if this is a home care company, hospital, or private clinic. The layers consist of different management that works with staff to make sure everything is done correctly and followed by the rules. A health care organizational structure can be different with made up of many individuals for example of directors of each department, board of directors of the company, patient care managers, all the way to direct care workers. In Professional Medical Home Health the organizational structure was compromised from the top level down. Six individuals of Professional Medical Home Health were indicated in the participation of the insurance fraud with submitting false statement to the government health care program (Medicare).

The idea of having corporate laws with organization governance was not used within this company. Corporate governance is the processes, policies, and regulations with the organization and people. Organizational governance is there to enforce the rules and laws to focus on the quality of care of patients. In this situation, the organizational governance broke the law of the False Claims Act by submitting fraudulent billings to get more money for themselves. With the fraud...

References: (2014). Six Defendant Charged in $6 Million Miami Home Health Care Fraud Scheme. Retrieved from (2014). Health Care Fraud Prevention and Enforcement Efforts Result in Record-Breaking Recoveries Totaling Nearly $4.1 Billion. Retrieved from
Hubbell, T. D., Mauro, A. C., & Moar, D. (2006). Health care fraud. The American Criminal Law Review, 43(2), 603-661. Retrieved from
Raven, C. (2014). The Intersection of Health Care and Organizational Ethics. Retrieved from
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