Thesis (M.H.A.)--University of Michigan, 1977.

Thesis (M.H.A.)--University of Michigan, 1977.

Thesis (Ph. D.)--University of Missouri-Columbia, 2002. / Typescript. Vita. Includes bibliographical references (leaves 74-78). Also available on the Internet.

Thesis (Ph. D.)--University of Missouri-Columbia, 2002. / Typescript. Vita. Includes bibliographical references (leaves 74-78). Also available on the Internet.

In the fiscal year 2014, approximately 1,337 health care providers lost their provider license to Medicare/Medicaid fraud. Out of the 1,318 criminal convictions reported by the U.S. Medicaid Fraud Control Units (MFCU), 395 (30%) were home health care aides who claimed to have rendered services not provided. The purpose of this multiple case study was to explore licensed and certified home health care business managers' strategies to mitigate Medicare/Medicaid fraud risk. A purposive sampling of 9 business managers and chief executive officers from 3 licensed and certified home health care businesses in Franklin County, Ohio participated in semistructured face-to-face interviews. Data from the interviews were transcribed, coded, and analyzed to identify themes regarding Medicare/Medicaid fraud risk management strategies. Drawing from the Committee of Sponsoring Organization's internal control framework and fraud management lifecycle theory, 5 themes emerged: the control environment, risk assessment, control activities, information and communication, and monitoring activities. Findings from this study included maintenance of integrity and culture, training and educating both staff and clients about fraud reporting processes and the consequences of fraud, rotating staff on a regular basis, performing fraud risk assessments, implementing remote timekeeping and monitoring system, and compensating shift leaders to coordinate activities in the clients' residences. The implication for positive social change includes reducing healthcare cost for all taxpayers through Medicare/Medicaid fraud reduction.

Healthcare fraud is a major problem within the healthcare industry. The study examined medical fraud, its laws, and punishments on federal and state levels. It compared medical fraud to non-fraud crimes done in the healthcare industry. This comparison will be done on a state level. The study attempted to analyze the severity of fraud against non-fraud and that doctors would commit fraud offenses more often than non-fraud offenses.

The medical scheme industry in South Africa is competitive in relation to international standards. The medical scheme sector, as part of the healthcare industry, is negatively affected by the high rate of fraud perpetrated by providers, members and syndicates, which results in medical schemes funding fraudulent claims. The purpose of the study was to explore strategies to mitigate fraud in medical scheme claims. A qualitative research methodology was followed in this study, which adopted a case study approach. Empirical data was analysed through thematic analysis, with the aid of ATLAS.ti software. The study found that healthcare service providers mainly defraud medical schemes by submitting false claims. A holistic approach should be followed to mitigate fraud in medical scheme claims. This approach should encompass regularly identifying trends in fraudulent claims and implementing appropriate control strategies. Collaboration within the medical scheme industry and with other stakeholders would also help to elevate the fight against medical scheme fraud to a new level. Implementing the recommendations from the study will assist medical schemes to reduce the funds expended on fraudulent claims, thereby improving their financial viability and decreasing the rate of increase in medical scheme contributions for members. / Business Management / M. Com. (Business Management)