Healthcare - The Truth About

Healthcare - the Truth About Fraud

In a quest to deeply understand the various management theories in healthcare today, this report uses an approach of first trying to understand some of the healthcare industry's concerns which in turn affect their options when applying their management theories. The article chosen was authored by Chris Farnsworth and is entitled 'The Truth About Fraud' which was in the May 1, 1997, Washington Monthly. The media today consistently puts out a message that the healthcare industry is currently trying to tackle concerns around the likes of fraud, abuse and waste. No management team in any industry will ever be able to produce an outstanding product or service if that team' management theories must first contend with these types of issues. The healthcare industry is no exception. The leaders in the healthcare community have their management theories geared first to deal with fraud and waste and secondly to move towards profitability. Fraud and waste are the types of alarms that alert the media to the many holes in an all ready pressured management process. This article review therefore focuses on one of the healthcare industry's biggest management concerns which affect the viability of any management theory.

The author through his article points out how fraud is a crime perpetrated by a large number of medical providers, employers of the insured or the insured members themselves. These crimes occur because until recently, the majority of Federal and State programs such as Medicaid were not adequately prepared to deal with fraud. Fraud in the healthcare payment system has been estimated to cost the public and the industry billions of dollars annually. Of course, there are no precise methodologies to accurately pin down a dollar amount but most authorities contend that insurance fraud is at minimum a one hundred billion dollar problem annually.

Therefore, one of the biggest concerns in the healthcare industry today is fraud and that directly affects the types of management theories that can be implemented. No healthcare management theory will be effective if there is a continued trend of rising costs within the United States healthcare system. These costs most be controlled. and, since one of the major driving factors for these rising costs has been billing and payment fraud, the healthcare industry leaders as well as governmental bureaucracies must solve the associated problems. We can consider healthcare payment fraud as any attempt by an individual or group, including whole organizations, which present some type of fraudulent claim in so as to intentionally deceive an insurer such as the Medicare or Medicaid systems as well as the various private insurers. Anytime a person or group is the beneficiary of receiving some type of unauthorized reimbursement or payment can technically be considered fraud.

As the article shows, healthcare fraud done by a medical provider could be as simple as malicious medical billing for services not provided to presenting ghost prescriptions and anything in between. The most common type of fraud by far is that of requesting reimbursement for a non-covered or non-performed service. These come in the form of billing that is actually a deliberate duplicate service. Next on the list would be performing medically unnecessary services. To many doctors are trying to obtain reimbursement by misrepresenting dates, description of service so all of these fall under the category of healthcare payment fraud. The healthcare industry leadership spends countless hours trying to implement management theories that can thwart common fraud such as incorrectly reported diagnoses to maximize reimbursement. Not surprisingly, providing false employer group membership information has become a very common fraud occurrence. The phantom patient is also a technique that medical providers use.

The Healthcare leadership does not only have external concerns. Internal fraud from employers and employees has escalated as a problem as more and more employers falsely pad their rosters in order to secure healthcare coverage discounts based on larger enrolments. Employers also have been enrolling individuals not eligible for healthcare coverage based on dates of hire or termination which also expands overall employer coverage rosters. Individual members also commit various acts of fraud including sharing benefits by using someone else's coverage or insurance card, filing false or erroneous claims for services or medications never received.

In conclusion, this article was a review of Chris Farnsworth's 'The Truth About Fraud' from the May first 1997 Washington Monthly. Even though healthcare payment fraud is punishable by both imprisonment and large fines, there are no shortages for those willing to take the associated risks. This insight provides a foundation for really understanding the various management theories in healthcare today. Healthcare management has been forced to adopt defensive options first when applying their management theories because the media continues to put out the word that the healthcare industry cannot hide its track record of trying to deal with the issues of fraud, abuse and waste. It is common knowledge that no management team's organization can create or give products or services when that organization is contending with these things. The leaders in the healthcare community will continue to implement management theories to deal with fraud and waste because those are the hot buttons for the media and public alike.

Article 2

Healthcare Delivery System

This article review focused on Healthcare Delivery Systems as a specific organizational structure in healthcare. The story covered was an Internet based article called 'Current Telehealth Applications' which was on the Telehealth Applications web page. As more and more seniors in America face the challenges of being able to afford prescription medicines, the healthcare industry has begun to lose some of its long time accepted bricks and mortar constitution. The existing healthcare delivery system for example has not been able to meet the needs of the older and poor patients in our country due to the high costs and the lack of healthcare coverage for those types of Americans. Apparently, the United States is not the only place in the world that has these obvious problems. The new healthcare delivery system of the twenty first century and beyond will be a system without walls or buildings because the economics of globalization and the convenience of the internet have begun to move into healthcare.

It is more than obvious that America's population continues to age. The baby boomers will be fully retired soon so more seniors will require medical attention based on the needs of the elderly. However, the problems of those already in the upper years will show that the existing healthcare structure will have to change in order to meet the needs of the community. Currently, a large number of our existing senior citizens are already in a position where they cannot afford the costs associated to their basic medicine prescription needs. Those seniors are beginning to move to cheaper sources for those needs as the basic rules of supply and demand kick in. For example, how many of the seniors in America have begun to look across the northern boarders of America into Canada for their prescriptions to be filled. There is obvious cost relief coming out of Canada because their Healthcare Delivery System is known for providing drugs at a much lower rates then here in the United States.

As the article pointed out, a great many medical philosophies begin in other parts of the world as each nation attempts to create a sound healthcare system. The goal of a good healthcare system seems like a universally accepted objective. One way that nation's in Europe have begun to adapt to new technology available is to utilize borderless pharmacies through innovative ideas like telehealth and telemedicine. The American seniors faxing prescriptions to Canadian pharmacies or utilizing the Internet or email to get those prescriptions abroad are using telehealth and telemedicine.

The process works by the senior faxing a prescription to a Canadian, or any nation's, pharmacy and then sends payment with a credit card or a check in the mail. The pharmacy once paid utilizes the overnight delivery industry giants such as FedEx and the medicine can be delivered the next day if need be. The internet and email have even sped up the process to become almost an instant transaction with the added benefit of a fax as secondary failsafe. Our senior's situation seems to have become a healthcare delivery system trend throughout the world. "It is striking how the issues related to integration of telehealth/telemedicine into healthcare delivery are common to many countries." (Telehealth Applications, 2004)

The United States healthcare organizational structure will indeed have to take on a new look in order to incorporate the available technology into the system. For example, new privacy laws based on the HIPAA laws will require the bulk of our nation's healthcare facilities to invest in new hardware and software technologies in order to secure the privacy of their patients as well as to communicate with the upgraded governmental Medicare and Medicaid system requirements. In the past, our healthcare delivery systems only utilized local facilities and characteristics but with our seniors have discovered, the twenty-first century's healthcare delivery systems will be global and the United States organizational structure will have to comply.

The experiences of seniors within the healthcare delivery system will alter how all Americans view healthcare. The healthcare delivery systems and overall organizational structure in the United States has been slow to adjust but that rest of the world is currently in flux that will migrate into our system. Technological advances in communication have made telehealth and telemedicine vialbel solutions to our outdated healthcare industry orgainzational structre. While these types of advances are only in their infancy, "...there seemed to be broad acceptance that telehealth and telemedicine had provided positive benefits to the worlds healthcare delivery system." (Telehealth Applications) Our technoloically challenged seniors have actually discovered the trend within the healthcare system and telehealth and telemedicine seems to be an advance that will find worldwide support so we as a nation will be reqquired to jump on the bandwagon.

In conclusion, this article review focused on new Healthcare Delivery Systems which will change the United States healthcare industry organizational structure. The story was an Internet based article called 'Current Telehealth Applications' on the Telehealth Applications web site. The trend of more and more seniors throughout our nation having to face the challenges associated with skyrocketing prescription costs and the fact that our poor have to deal with no medical coverage at all has begun a process of breaking down the old structure of bricks and mortar healthcare. The existing healthcare delivery system has not been able to meet the needs of our older and poor citizens so the high cost and the lack of healthcare coverage for those Americans will change the structure as we know it. Since the United States is not the only place in the world that has these problems, the new healthcare delivery system of the twenty first century and beyond will be a system that has no walls or buildings due to the economics of globalization and the convenience of the internet.

Article 3

Motivation in Healthcare

This article review relates to the principles of leadership in healthcare management. The article reviewed was by Mabel Joshua-Amadi and is called "Recommendations: A Study in Motivation: Recruitment and Retention in the NHS" from the February 2003 Nursing Management Journal. The current healthcare industry leaders are not adequately motivating their employees to a point to where they are enjoying what we can deem as job satisfaction. The objective the article was to analyze the nature of motivation and also detailing how motivation applies to the recruitment process. This article made it very clear that current staff levels in the healthcare industry suffer due to shortages in the overall healthcare industry. Nurses hold a great responsibility to the overall industry success but the current healthcare shortage is a more wide spread than simply filling nursing roles. The entire industry from specialized janitorial workers to high tech radiology specialists are in high demand. The intent is also to provide insightful details into some of the myths regarding human motivation and existing hiring practices.

There are various factors working against the healthcare industry management regarding motivation and leadership. The first item is that the population of the United States continues to be an aging group. In other words, the industry will find it difficult to replenish its numbers of new nurses and techs. Secondly, the industry is just to slow in building bench strength for its current nurses nearing retirement. And third, people don't like the jobs. The industry's moral is at all time lows due to the fact that expected retirements, tenure and union like work ethics, poor and hazardous working conditions, low pay and poor floor management practices don't translate into happy workers. "The relationship between organizations and their workforces is governed by what motivates individuals to work at their best and the satisfaction they derive from their activities." (Joshua-Amadi) large concern for the industry has been retention which is a very different animal than recruitment even though they are related for Human Resource managers. The current healthcare shortages show that the industry has some major gaps to fill. Shortages are made worse by high turnover and lack of job satisfaction by many throughout the industry. "Studies have tried to elicit and predict reasons for high staff turnover in order to limit cost and adverse effects on morale, enthusiasm and organizational reputation." (Joshua-Amadi)

One would think that with the large amount of recruitment and retention problems that the healthcare industry management is facing that they would be working overtime to create situations to help maintain existing staff morale or motivation. but, studies consistently show that many nurses are still not happy and that a lot more can be done on the part of management to resolve some of these issues. Current problems revolve around personal factors such as employers not providing opportunities for learning, job satisfaction, retirement, monetary benefits, easier patient care and job security.

The crisis will only be getting worse. Over the next decade, the demand for nurses and other skilled healthcare employees will continue to increase as our aging workforce will dramatically reduce the number of skilled workers that are available. The Baby Boomer generation continues to move closer to retirement which entails that there will literally be fewer young people to get the job done. It is therefore imperative that the current healthcare leadership promotes and develops viable methods to help build organizational ties with nurses and other clinicians before those imminent shortages take hold.

Human Resource departments have consistently found that the healthcare industry employees are known for being bored, discouraged, underpaid and unmotivated. But simply raising pay scales will not be enough. Therefore, it is most likely a leadership issue that causes these reactions by staffs. "Effective leadership and managerial support can reduce staff frustration and dissatisfaction while increasing productivity and retention. Without extra effort being put into motivating trained staff, many more will leave." (Joshua-Amadi)

It is a falsehood that existing nurses and radiologists are paid well and therefore should be satisfied that they are in such high demand. "Motivators can be extrinsic and tangible. Examples include pay, job security, safety, promotion, pensions, employee friendly policies and favorable working conditions. Or they can be intrinsic and intangible, with examples including opportunity to perform, challenge, sense of achievement, personal growth, positive recognition, and being appreciated, valued and treated with respect, care and consideration. These form part of the unwritten psychological contracts between employees and organizations -- contracts that are at the heart of motivation and organizational effectiveness. Their fulfillment ensures employee loyalty, trust and commitment." (Joshua-Amadi)

In conclusion, this article was a review relating to the principles of leadership in healthcare management. The article reviewed was by Mabel Joshua-Amadi and was called "Recommendations: A Study in Motivation: Recruitment and Retention in the NHS" from the February 2003 Nursing Management Journal. As the author points out, the current healthcare industry leaders are not adequately motivating their healthcare employees to a point to where they are getting job satisfaction. The objective of the article was to analyze the nature of motivation and also to detail how motivation applies to the healthcare industry's recruitment process. This article made it very clear that current staff level shortages will become more widespread in the healthcare industry. That should be of major concern for the industry because nurses and other specialized fields are so important to the overall success of healthcare.

Article 4

Decision Process in Healthcare Organizations

This article focused on the overall decision making process within the healthcare organizations. For the rest of the twenty-first century, the need for privacy will change how organizations in the healthcare industry can make decisions. The article reviewed was authored by Daniel J. Soloye and was called, "Privacy and Power: Computer Databases and Metaphors for Information Privacy" and was out of the July 2001 Stanford Law Review. The United States healthcare system includes many factors such as health plans, physicians, hospitals, clinics, consumers, and public health programs. Today, whenever a consumer has to choose either a health plan, physician or other health professional, that consumer will have private information such as a social security number or a specific diagnosis pass through the many hands, computer systems and files which is our healthcare system. "Almost all of us are aware that our personal information is being collected and stored by many different entities." (Soloye) the internet, identity theft and other concerns such as credit card fraud have all contributed to a need for increased privacy which in turn will require the healthcare organizations to be further mandated by law to protect the patient related data that is considered private. The daunting task will be made even more difficult considering that the healthcare organizations will still be help to a standard of providing outstanding service while protecting that privacy.