Root Cause Analysis Using Five Whys

Root Cause Analysis Using Five Whys

Read the news report “Maryland Health Care Provider Sentenced to 10 Years in Federal Prison for Health Care Fraud Resulting in Patient Deaths.”
Use the Five Whys to conduct a root cause analysis to determine why the Medicare fraud occurred and Timothy Emeigh’s participation in the case.
Write a 750 to 1050-word paper that identifies and evaluates the root cause for Medicare fraud in this case.

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As a result, over the last two decades, several legislations have been enacted to assist the Office of Inspector General (OIG) to investigate and prosecute offenders that have committed fraudulent billings against the taxpayer funded insurance system. Medicare database systems are not discovering fraud until after the fact and thus recovering funds can be challenging. The enactment of stringent enrollment procedures should decrease the amount shell companies submitting payments for no services. Furthermore, utilization of forensic accountants should be employed to locate identity fraud within the Medicare system. The integrated data repository will allow access to files in one location for advance analysis to detect fraudulent claims. The False Claim Act has been successful in prosecuting, collecting monetary sanctions from offenders. Furthermore, the Recovery Audit Contractor provides additional oversight of payments in specific vulnerable areas. This has led to a reactive approach in dealing with fraudulent transactions. Due to the sheer volume of billing received each month, it is impossible for the system to review all the information before payment has been released to providers.

“The evidence showed that Rafael Chikvashvili failed to provide medical services to patients who needed them, and billed for services that he did not provide,” said U.S. Attorney Rod J. Rosenstein. “The jury found that two patients died because their X-rays were not reviewed by a qualified radiologist. Health care fraud has consequences, in money wasted and lives lost.”

According to the District of Maryland, the five reasons why Chikvashvili fraud was caught was “based on the evidence, the jury found that from 1997 through October 2013, Chikvashvili conspired with others to defraud Medicare and Medicaid by” (2016):

1. Creating false radiology, ultrasound and cardiologic interpretation reports.
2. By submitting insurance claims for medical examination interpretations that were never completed by licensed physicians.
3. By falsely representing to Medicare and Medicaid, as well as to treating physicians, that the interpretations had, in fact, been completed by actual licensed physicians.
4. By submitting insurance claims for radiology, ultrasound and cardiologic examinations (and their associated costs) that were never performed and/or were not ordered by the treating physician.
5. By submitting claims for transportation and other charges that Alpha Diagnostics was not entitled to receive.

According to witness testimony, Chikvashvili instructed his non-physician employees, including Emeigh, to interpret X-rays, ultrasounds and cardiologic examinations instead of licensed radiologists. For example, in June 2012, Emeigh traveled to Jamaica for a vacation.  The evidence showed that Chikvashvili directed Emeigh, through text messages and telephone calls, to view medical images using his personal laptop in his hotel room and then draft false physician interpretation reports.  Alpha Diagnostics personnel subsequently submitted false claims to Medicare for these images and fraudulent physician reports.

Emeigh told investigators that prior to the fraud scheme being shut down, he was doing nearly 80 percent of Alpha Diagnostics’ X-ray interpretations in Maryland—readings that should have been done by a licensed physician. “He probably did tens of thousands of them over the course of the fraud,” Custer said. “There is no telling how many patients suffered or died because of these crimes.”

The government has been pursing Medicare and Medicaid fraud more aggressively, said James Quiggle, a spokesman for the Coalition Against Insurance Fraud, a watchdog group. But it’s unusual for them to try to link the activity to deaths. Most health care providers who are accused of defrauding the government are trying to “fly under the radar,” Quiggle said.

They are more likely to pay their bills or steal patients’ identities and make up claims, he said, rather than provide substandard care — which invites scrutiny from other medical providers and law enforcement.

“Scammers in general are concerned less about rendering quality care and more about milking the system for every penny they can,” Quiggle said. “You can run a fine line between shoddy health care and endangering a patient’s life.”

• Cohn, M. (2015, April 11). Owner of imaging firm linked to patient deaths in indictment. Retrieved April 08, 2018, from http://www.baltimoresun.com/news/maryland/crime/bs-md-alpha-diagnostics-indictment-20150410-story.html
• Health Care Provider’s Crimes Caused Patients’ Deaths. (2017, May 02). Retrieved April 06, 2018, from https://www.fbi.gov/news/stories/health-care-providers-crimes-caused-patients-deaths
• Maryland Health Care Provider Sentenced to 10 Years in Federal Prison for Health Care Fraud Resulting in Patient Deaths. (2016, June 15). Retrieved April 06, 2018, from https://www.justice.gov/usao-md/pr/maryland-health-care-provider-sentenced-10-years-federal-prison-health-care-fraud

Root Cause Analysis Using Five Whys