Exam Content
Throughout this course, you have examined occurrences of the types of health care noncompliance, fraud, and abuse that commonly take place in the context of the regulatory environment in which organizations must operate. To ensure the best chance of avoiding intentional and unintentional noncompliance, health care administrators should devise and adopt a risk management plan that identifies, assesses, and analyzes the risks and tolerances inherent in the organizations processes and operations.
One of the crucial aspects of a risk management plan involves strategies for actions that should be taken in the event of a violation or breach of any nature. These mitigating actions should be followed up with remediation aimed at finding the causes leading up to the incident. This is where root cause analysis comes into the picture.
Root cause analysis is a structured, retrospective analysis of events leading up to the noncompliant event. By developing an organization-wide policy for conducting root cause analyses that is adaptable to specific operations, a cause might be determined, and preventive actions and solutions developed.
In this assessment, you examine a case of fraud and try to determine why and how it happened.
Read Maryland Health Care Provider Sentenced to 10 years in Federal Prison for Health Care Fraud Resulting in Patient Deaths from the United States Attorney’s Office. (LISTED BELOW)
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 700- to 1,050-word analysis that identifies and evaluates the root cause for Medicare fraud in this case.
Include the following:
Articulate the “Five Whys” for this case and provide an explanation for each.Speculate how and why Mr. Emeigh participated in the scheme.Explain what you, as an administrator, might have done to prevent this from happening.Recommend risk management strategies the organization can utilize to prevent this and similar types of events from occurring in the future.
Cite your sources according to APA guidelines.
Maryland Health Care Provider Sentenced to 10 Years in Federal Prison for Health Care Fraud Resulting in Patient DeathsPatients Died Because No Radiologist Reviewed X-Rays; Defendant Cheated Medicare and Medicaid of More Than $6 MillionBaltimore, Maryland – U. S. District Judge James K. Bredar sentenced the owner of Alpha Diagnostics, Rafael Chikvashvili, age 69, of Baltimore, Maryland, today to 10 years in prison, followed by two years of supervised release, for charges related to a health care fraud and wire fraud conspiracy resulting in the deaths of patients, as well as false statements and aggravated identity theft, related to a scheme to defraud Medicare and Medicaid of more than $6 million. Judge Bredar also ordered that Chikvashvili pay restitution and forfeit proceeds of the fraud, with the exact amount to be determined at a later date. Chikvashvili has been detained since his conviction by a federal jury on February 17, 2016.
The sentence was announced by United States Attorney for the District of Maryland Rod J. Rosenstein; Special Agent in Charge Nicholas DiGiulio, Office of Investigations, Office of Inspector General of the Department of Health and Human Services; and Special Agent in Charge Kevin Perkins of the Federal Bureau of Investigation, Baltimore Field Office.
“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 evidence presented at the two-and-a-half week trial, Chikvashvili formed Alpha Diagnostics Services, Inc., which later became Alpha Diagnostics, LLC, in 1993, and was the Managing Member, Authorized Official, Managing Employee, President and Chief Executive Officer for Alpha Diagnostics. Chikvashvili holds a PhD in mathematics, but was never a medical doctor or licensed physician. Timothy Emeigh was the Vice President in charge of Operations at Alpha Diagnostics and was a licensed radiologic technologist.
Alpha Diagnostics was a portable diagnostic services provider, principally of X-rays, but also provided ultrasound tests, and cardiologic examinations. Alpha Diagnostics’ clients included nursing homes whose patients were covered by Medicare and Medicaid. Alpha Diagnostics operated in Maryland, Delaware, Pennsylvania, Virginia and the District of Columbia, but was headquartered in Owings Mills, Maryland, where Chikvashvili worked full time.
Based on the evidence, the jury found that from 1997 through October 2013, Chikvashvili conspired with others to defraud Medicare and Medicaid by: creating false radiology, ultrasound and cardiologic interpretation reports; by submitting insurance claims for medical examination interpretations that were never completed by licensed physicians; 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; 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; and 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.
The evidence showed that Chikvashvili also caused employees to draft licensed physician’s examination reports. Chikvashvili, in turn, caused a copy of the handwritten signature of the actual physician to be affixed to the report, or forged the physician’s signature himself, creating the appearance that a licensed physician had performed the medical interpretation.
According to the testimony provided at trial, two patients died because their X-rays were not interpreted by a qualified radiologist. Instead, non-physician Alpha Diagnostics employees reviewed the images and failed to detect congestive heart failure. As a result of the incorrect reading the her chest X-ray, the first patient with congestive heart failure was not transferred to an acute care facility for treatment, as is standard medical practice, but remained in a rehabilitative nursing home. The patient died four days after unqualified Alpha Diagnostics personnel misinterpreted her chest X-ray. Witnesses testified that had the patient been transferred, her symptoms could have been addressed. The second patient was scheduled to undergo elective surgery and the chest X-ray was a pre-operation test to determine if the patient could safely have surgery. According to the evidence presented at trial, although the patient’s X-ray revealed mild congestive heart failure, the non-physician Alpha Diagnostics employee failed to detect it. A patient in congestive heart failure is at an increased risk of bleeding during and after surgery. As a result of the incorrect reading of the chest X-ray, the patient was cleared for elective surgery and experienced significant bleeding after the elective surgery, and the worsening of her congestive heart failure. Six days after unqualified Alpha Diagnostics personnel misinterpreted her chest X-ray, the patient died.
Subsequently, Alpha Diagnostics submitted claims to Medicare falsely representing that licensed radiologists had interpreted both patients’ chest X-rays. Medicare paid Alpha Diagnostics $8.87 for the first claim and $218.36 for the second claim.
The evidence showed that over the course of the conspiracy, Chikvashvili and Alpha Diagnostics received more than $6 million from fraudulent claims submitted to Medicare and Medicaid.
Timothy Emeigh, age 51, of York Springs, Pennsylvania previously pleaded guilty to health care fraud and is scheduled to be sentenced on June 17, 2016.
United States Attorney Rod J. Rosenstein praised the HHS-OIG and the FBI for their work in the investigation. Mr. Rosenstein thanked Assistant United States Attorneys Leo J. Wise and P. Michael Cunningham, who prosecuted the case.
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