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SCIENTIFIC MERIT ACTION RESEARCH TEMPLATE (SMART) FORM Featured

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Section #1

To be completed by Learner

1.1 Learner Name

YOLANDA WRIGHT

1.2 Learner Program

Doctor Health Care Administration

1.3 Learner Email

 

1.4 Learner Phone

 

1.5 Mentor Name/Email

N/A

1.6 Committee Member #1 Name/Email

N/A

1.7 Committee Member #2 Name/Email

N/A

1.8 Dissertation Title

Healthcare  Billing Fraud in the State of California

1.9 Site Selected

California

1.10 Contact Info for Site Approver & Expected Approval Date

Since I’m not choosing a specific venue not sure what should go here

Section #2

To be completed by Learner

 

2.1 Project

 

 

The research topic is health care billing Fraud for the State of California. California is one of the first states to formulate and implement antifraud laws. However, the rate of health care billing fraud in the state remain relative rampant.  These frauds continue to drain an already struggling health care system. Therefore, there is an immense need to understand the dynamics of medical billing fraud in the state such as factors that precipitate fraud, cost of fraud to consumers, effectiveness of the antifraud system and successful ant-fraud interventions.

 

2.2 Contribution to Society

 

 

The current health care billing system is complex and prone to errors (Varshney, 2010). It is essential to appreciate that healthcare is a dynamic and segmented market among parties that deliver or facilitates the delivery of health information, resources, and financial transactions that move along all components. Health care fraud remains a huge problem in the USA health care system. In 1993, medical billing fraud was rated the second crime problem after violent crime. Although the political, social and economic landscape of the country has changed since then, medical billing fraud remains a top priority for stakeholders due to the large financial implication to taxpayers. It is estimated 3% to 10% of national health care funding is lost to fraud (Dietz, Gamble, Marchlowska, & Wheeler, 2013)

According to Douglas (2010), the ease of defrauding health care programs such as Medicaid and Medicare has attracted a new type of criminal who are exploiting the system. 

Understanding the major factors that precipitate health care fraud will assist organizations in formulating organization change to reduce incidences of fraud at the organization level.  The research also seeks to understand the cost of health fraud to the customer. Most of the past health care frauds have been analyzed in terms of the cost to the national or to the victim organization. However, it is essential to understand the non-monetary impact of fraud to consumers so as to mobilize lobby groups to push for policy change.  In addition, the researcher seeks to investigate the effective of the current antifraud law and policies in California. It will inform policy makers in California on the need to change or strengthen the existing antifraud framework.  Lastly, the research will outline some of the success antifraud policies in other states by conducting case analysis and literature review. It will provide best practices and recommendations to health care providers in the state on implementing successful antifraud framework. 

 

2.3 Need and Evidence to Make Change

 

 

Health cares fraud strain health care expenditure and reduces the quality of care. The practice has negative implications not only to the taxpayers, but also to the consumer of health services and the perpetuating person or organization. With the increased emphasis on reducing the cost of care, arresting the fraud problem ranks among the priority for most states and institutions.

 

2.4 Theoretical Foundation

 

backbone of your project. Provide references for each theory.

 

Medical billing fraud has been historically considered a white collar crime and much of the theoretical probe of the problem falls under white collar crime (Sparrow, 2009). In order to address the problem of medical billing fraud, particular institutional and health program factors that lead to fraud and theoretical causes of the problem need to be understood. Health care professionals make a rational decision to commit fraud while others choose to be honest in billing. The rational choice and routine activities theories argue that medical billing fraud results into greater benefits than costs to perpetrators (Simpson, Piquero, & Paternoster, 2002). Therefore, fraud involves a conscious decision to break regulations to achieve greater monetary gain. On the other hand, the deterrence theory provides a quicker and strict prosecution of medical billing fraudsters and provides and effective preventive measure to reduce the crime.

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2.5 Researcher Positionality

The researcher will be involved directly in the study.  It is the role of the research to seek the necessary approval for the study, compile the research proposal and seek approval and consent from the necessary authority. The researcher will be involved in the actual study process such as sampling, data collection and analysis and result presentation.  However, the research will require external assistance and collaboration from institutions that will be involved in the study and research assistants to help in data collection and analysis.

 

2.6 Research Questions and Project Goals/Objectives 

The purpose of the study is to understand medical billing fraud in California. The research questions include:

What are the factors that promote medical fraud?

What are the impacts of medical billing fraud to the consumer?

How effective are fraud prevention and detection systems in the state?

What intervention strategies are effective in preventing and detecting medical fraud?

References

Dietz, J., Gamble, W., Marchlowska, J., & Wheeler, B. T. (2013). Fighting Health Care Fraud in Bold and Innovative Ways. Military Medicine178(10), 1041-1043. doi:10.7205/MILMED-D-13-00205

Lundqvist, H., Birbach, N., Carney, T., & Heyd, B. (2012). HEALTH CARE FRAUD.American Criminal Law Review49(2), 863-928 Lundqvist, H., Birbach, N., Carney, T., & Heyd, B. (2012). HEALTH CARE FRAUD. American Criminal Law Review, 49(2), 863-928

Sparrow, M. K. (2009, May 22).

Malcolm Sparrow testifies before the Senate Subcommittee on criminal prosecution as a deterrent to health care fraud.

Janet Peter is the Managing Director of MeldaResearch.Com a globally competitive custom writing service which is the premiere provider of Essay Writing Services, Research Paper Writing Services at Term Paper Writing Services at very affordable cost. For 9 years, she has helped a number of students in different academic subjects.

Read 150 times Last modified on Wednesday, 20 December 2017 11:12
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