The success or downfall of an organization rests on the organizational structure and culture influence. In order for an organization to be successful, there are several incidents that they must work to prevent, such as health care fraud and abuse. This paper will review fraud and abuse and how organizational structure and governance, culture, and focus on the social responsibility affect or influence the described situation. This paper will also overlook resources and allocation to prevent situations n the future and the ethical issues that may relate to the determination of the described solution. Furthermore, this paper will work to provide recommendations for changes surrounding structure or culture for an organization in order to prevent situations from happening in the future.
Health Care Fraud
While reading the local newspaper recently, I came across a story about an outpatient psychiatric clinic for the mentally ill senior citizens that was charged with health care fraud, and that an investigation had been ordered. The clinic, which is located in a low-income urban area, was charged with health care fraud after several of the clinics psychiatrists were caught arriving to the clinic, asking the nurse on duty how the patients were doing and then would base psychotherapy notes on the nurses feedback and then charge Medicare for 50 minutes of sessions. The investigation showed that one third of the claims that were submitted to Medicare were up coded and the clinic was billing each of those “services” individually as opposed to charging one daily rate, which is directed by the Medicare contract. Through the investigation, other inappropriate charges were brought to the surface, such as referrals by local family physicians for a fee of $100 for patients who did not have a mental conditions but had a condition that could have been treated by the clinics existing clinical services. Approximately, 90% of the clinics funds were supported by Medicare payments and the clinic physicians held the position of majority shareholders of the corporations and were on the board of directors (Mastin, 2000, para 8,9).
This clinic is the not the first clinic to charge fraudulent charges to Medicare, there are numerous stories in the media that surround similar incidents. For instance, a medical supplier was found guilty of five counts of fraud and sentenced to 120 months of jail time and restitution of $1.6 million. In another incident, a medical center known as Raritan Bay Medical Center settled charges for Medicare fraud charges for $7.5 million. In Illinois, a medical group known as Amerigroup, Inc was charged after refusing to register a pregnant woman. Examples such as these are clear demonstrations of fraud and abuse and they happen more than they should. In order to help to prevent from false claims from happening, a False Claims Act was created. The False Claims Act is the most commonly civil statue that is used when a health care provider is sued or charged with committing health care fraud. The Act ensures that the provider is charged with intentional wrongdoing and that the provider is faced with huge fines or imprisonment and possibly lose their medical license.
Organizational culture works closely with other aspects of an organization performance, such as; financial performance, customer, and employee satisfaction and innovations. Organizational culture in the health care environment has been linked to several fundamentals that contribute to quality, such as the position of the nurses, job satisfaction and the safety and satisfaction of patients and lastly, financial responsibility. When an organization is created, the organizational culture and structure is not an automatic thing. In order for an organization to reach the right culture and structure, persistent norms...