Date of Award

8-2016

Degree Type

Thesis

Degree Name

Criminal Justice (M.S.)

Department

School of Criminal Justice

First Advisor

Patrick Gerkin

Second Advisor

Jacquelynn Doyon-Martin

Third Advisor

Tonisha Jones

Abstract

Health care fraud is a crime that costs the United States billions of dollars each year. Health insurance fraud against government programs such as Medicaid and Medicare make up the majority of false claims. Government health care programs are particularly susceptible to fraud for three reasons: (a) high volume of claims; (b) recipient characteristics; and (c) a favorable ratio of reward to risk. Modes of fraud commission change depending on the health care delivery and payment model in use. In part, the Patient Protection and Affordable Care Act of 2010 sought to dramatically reduce health care fraud. The Affordable Care Act and related documents were analyzed using a qualitative, inductive approach that involved aspects of legal impact study and grounded theory methodology. The principles of Cressey’s Fraud Triangle Theory were applied with the goal of generating new hypothetical understanding about how the law influences pressure, opportunity, and rationalization in terms of the way the legislation was intended as well as its real world application. The Act decreases pressure by awarding grants and providing funding and incentives to institutions and individuals, thus improving their financial stability. In a small number of cases, the Act may increase pressure on specific entities by imposing financial penalties, although the purpose of these sanctions is to coerce compliance with requirements of the law. The Act has the strongest effect on opportunity through increased regulation and oversight, linking payment with quality and outcomes, reporting requirements, use of alternative payment methods, and innovative demonstration projects. The Act addresses rationalization by consistently endorsing a consensus-based, multi-stakeholder approach when it comes to the creation of operating rules and standards. Emphasis is also placed on public reporting of performance data and information related to safety and quality standards. This was found to have a culture changing effect in ways that discourage favorable definitions of trust violation. The study concludes that linking provider payment with performance and outcomes is the optimal way to control costs while safeguarding patient health and deterring fraud, waste, and abuse. Future studies should explore the impact of the Act after it has been fully implemented.

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