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 and values need to be reinforced and taught to the employees and management (Boan & Funderburk, 2003). For an organization, it is important to teach the culture and structure to the employees immediately after the hiring phase. By teaching the new employees when they first enter the organization will allow for the values and behaviors to become a norm faster.
In order for an organization to be successful, a clinics history and foundation have several barriers to overcome. In the main situation stated above, the physician set a tone of the organization’s culture, which sent messages that impacted the clinical values, structure and focus in a negative way. The organizational structure of the referred clinics created a workplace of anxiety, stress, lack of trust and a lack of social responsibility. The social responsibility needs to be understood by the employees as a moral obligation to do what is right. Its important for an organization to evaluate their organization’s culture every year, in order to ensure that their methods are working. If the evaluation shows room for improvement, it might be a good idea to change the culture in order to boost moral. Changing an organizations culture is a hard task, however, the changes will be a positive move for the organization.
An organization often considers change when a significant event occurs, such as fraud or abuse charges. For an organization to consider change there needs to be a understanding, a commitment and the proper tools. For management, its important to understand what needs to be changed, where the organization needs to be and how the change will support that vision. In the situation, the clinic had a lack of vision and commitment to social responsibility and it definitely had an influence on the current situation it’s now facing. The executives and management staff influenced the culture of the clinic because they were the ones who provided the decision-making and strategic direction. As a result, the physician’s actions affected the organizations ethical behavior.
Fraud and Abuse Prevention
In order for an organization to prevent fraud and abuse from coming into an organization, reinforcements through ethic-awareness programs should be used, and as well as compliance programs and training. An ethic awareness program is a program that works to prevent such conduct from happening. Employees should be given a chance to present concerns without punishment. An organization should implement a compliance program to ensure the organization is clear about the laws and regulations and also include periodic reviews for compliance. For employees to really understand ethics and to live by it, an organization has to be living proof that ethics can go a long way. An organization must be a leader to its employees.
Regulations and supervision of compliance must be used constantly in an organization, such as cases stated above no such thing existed. Employees of healthorganizations must be provided with training about ethics and related regulations, and given penalties for non-compliance. The department of medical billing must work to review the organization is administrating appropriate treatments and payments to the patients. Many organizations are found guilty with unethically charging the patient or government programs for unnecessary treatments to patients. Auditing of cost reports is a must and subject to proper disallowances as required (Mayer, 1995).
Change in Social Responsibility
An organization cannot change their organizational culture until it is clear as to where it wants to be and what is required for the change to be successful. The organization must work to determine what cultural elements best support the success of the organization. Work towards having physicians and staff unlearn from old behaviors and understand what changes are expected. This type of change does not happen overnight and it is important to understand that this change will require time, commitment, planning and proper execution. Change must begin with the leaders of the organization. Each part of the staff needs to be dedicated and understand the need to change, commit to it, and take full ownership of the change that is being constructed. By the leadership modeling this type of behavior it will help reinforce the commitment to change and show other employees the model behind the desired behavior.
In order for change to be implemented, it is recommended that physicians within the organization be removed as voting or controlling board members. The medical board would be reorganized to include board members who would have influence or financial gain from the organization. The newly structured board members will work to implement organizational policies and regulations that surround fraud, abuse and waste. The board members must provide a clear understanding of what is expected of the organization structure, goals, and a new mission shall be introduced. The board through constructive feedback will provide a discouragement of unwanted behaviors, verbal and written warnings that can lead to termination.
New board members will ensure that physicians will provided proper documentation of patient visits. All employees within the organization will be mandated to participate actively in ethic awareness and compliance programs, and a strict punishment will be provided for non-compliance. There will be regular scheduled reviews to ensure compliance and billing practices are being implemented and performed by an outside agency. As employees work towards the new changes and adhere to them on a daily basis, opportunities to be rewarded are available. The plan is to have employees to find it hard to separate the organizational expectation from their own, in doing so the organization will reach a new level of success (Ritchie, 2000, p. 4).
In a health organization, culture is a major factor that is an organizations desire to innovate and evolve. By creating a style of leadership, structural stability, an ability to change all contributes to a culture of an organization. Changing the culture of an organization is not an easy task. A staff must work towards unlearning old behaviors and learning new ones. It at times can seem near impossible to change an organization from old ways, but it can be done. An organization can achieve their desired vision by changing their physical structure, values and culture. The executives of an organization create ad set the structure and culture, and must shows behavioral support based on the values, and beliefs of the organization.
An important aspect of achieving organizational outcomes is by communicating cultural values and accepted behaviors. Keeping in touch with employees and ensuring a commitment is active is critical for organization to be successful. Ensuring that all department goals and individual performances are in line is vital to the desired organizational culture. When an organization is working towards changing their culture its important that they work to continue evaluating their weaknesses and strengths and learn to use them both in a counterproductive way while working to strengthen their weakness. An organization can only be successful if they work together as team rather than against one another.
Boan, D., Funderburk, F. (2003). Healthcare quality improvement and organizational culture. Retrieved October 3, 2012,
Mastin, Y.M. (2000). Journal of Law and Health: The punishment of “health care fraud.” Retrieved October 5, 2012, http://www.highbeam.com/doc/1G1-85016554.html
Mayer, C.M. (1995) Preventing fraud and abuse fallout – healthcare industry includes related article. Retrieved October 3, 2012, http://findarticles.com/p/articles/mi_m3257/is_n4_v49/ai_17000470/pg_2/?tag=mantle_skin;content
Ritchie, M. (2000). Organizational culture: an examination of its effect on the internalization process and member performance. Retrieved October 3, 2012, http://www.allbusiness.com/management/988816-1.html