Root Cause Analysis: Five Whys of the Health Care Fraud Resulting in Patient Deaths

Root Cause Analysis Paper
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After reviewing the Department of Justice article, "Maryland Health Care Provider Sentenced to 10 Years in Federal Prison for Health Care Fraud Resulting in Patient Deaths," I have established the Five Whys to perform a root cause appraisal geared at establishing the rationale for the Medicare fraud and Timothy Emeigh's engagement in the issue. Abuse of power or fraud, whether perpetrated by a group or an individual, derives from the integrity and character of the involved parties. This incident triggered the push for legislation to help investigative agencies identify and prosecute law-breakers for billings tailored to defraud the taxpayers' money in the public insurance scheme. Any individual in the leadership of healthcare organizations and systems needs to recognize the need to mitigate or prevent these cases from happening. This paper articulates the Five Whys and the rationales for the case, speculates the reasons for Mr. Emeigh's participation in the fraud, explains the role of the administrator in preventing this from happening, and incorporates risk management techniques to mitigate the risks of such events happening in the future.
Articulate the "Five Whys" for this case
The fundamental problem derived from the case scenario is that Timothy Emeigh and Rafael Chikvashvili were imprisoned for causing patient deaths due to their role in perpetrating healthcare fraud and violating the false claims act (FCA). The first why explores why this imprisonment happened. Emeigh and Chikvashvili got imprisoned because the company they worked for, Alpha Diagnostics, engaged in healthcare fraud as well as a wire fraud scheme resulting in patients' deaths and false statements, including serious identity theft linked to the plan to defraud Medicare and Medicaid more than six million dollars (Department of Justice, 2016). The second why explores how the fraud caused patients' deaths. The answer lies in falsifying the radiological reports and then presenting the falsified reports to the patient, indicating that a licensed radiologist reviewed them. This worsened the patients' conditions and undermined their health outcomes, culminating in their deaths (Department of Justice, 2016).
The third why relates to how Alpha Diagnostics created fabricated reports and submitted them to Medicare and Medicaid as seemingly authentic insurance claims. The company owner, Chikvashvili, either faked a doctor's signature or appended a doctor's seal to make the document appear valid. The fourth is why patients had to die because of such practices before the unscrupulous issue was unearthed. This demonstrates a lack of strict oversight on compliance from Medicate and Medicaid because they should have validated the claims through thorough background checks about Alpha Diagnostics. The fifth why offers the explanation for Medicare and Medicaid's failure to monitor Alpha Diagnostics' claimed presentation as well as demand that Chikvashvili certify that they complied with Stark Law and Anti-Kickback Statute before submitting claims (Department of Justice, 2016).
Speculate how and why Mr. Emeigh participated in the scheme
Mr. Emeigh participated o...