Lessons from Health Care Fraud Cases: Implications for Management of Health Care Entities

Fraud has been a major issue all throughout the health care industry. There have been many cases around the world in relation to health care fraud. There are several laws now that do try to reduce the amount of healthcare fraud, but more changes could and should be made to reduce it even more. Four different cases that have occurred within the health care industry have be analyzed in this project. It looks at the positives and negatives of each company’s internal control structure and provides suggestions for how to improve these internal controls to prevent fraud from reoccurring in the health care industry. It also gives examples of other requirements that can be put in place in order to reduce the amount of fraud that occurs. Fraud is very common within the health care industry due to weaknesses within the companies’ internal control systems and many improvements should be made in order to prevent fraud from continuing to occur in the future

The occurrences and potential mitigation of occupational fraud in the international non-governmental organisation (INGO) sector in Vietnam: an empirical holistic approach

Purpose – This research investigated the overall research question as follows: How do factors (individual-level, organisational-level, industry-level, and country-level) influence occupational fraud in the INGO sector in Vietnam? This thesis addresses occupational fraud or internal fraud, rather than external fraud, because the former accounted for the majority of losses due to fraud. Additionally, this thesis has two foci: what may contribute to fraud – the second focus, and what may prevent fraud – the first focus. Specifically, the first focus is on how effective organisational-level factors are at preventing or reducing fraud (undetected, suspected, actual/detected, and future). Whilst, the second focus is on factors (individual-level, organisational-level, industry-level, and country-level) that may contribute to fraud (future only). Design/methodology/approach – This study develops a conceptual model, built on the fraud triangle by Cressey in 1950. The model combines: fraud (undetected, suspected, actual/detected, and future); individual-level determinants (e.g. pressures); organisational-level determinants [e.g. organisational ethical culture (OEC), organisational ethics program (OEP), and organisational internal control (OIC)]; the industry-level determinant (e.g. the non-profit nature); and country-level determinants (e.g. cultural, political, legal, economic, and technological). The methodological choice of research design is quantitative, using the survey strategy with a self-administered questionnaire to collect data. The questionnaires were administered to the entire target population of 408 INGOs (a census) in Vietnam. In each INGO, only one potential survey respondent was approached. Potential respondents were high-level staff members such as Chief Executive Officers (CEOs), Chief Financial Officers (CFOs), Chief Accountants (CAs), accounting/auditing/financial employees, and other managers (e.g. human resources managers). In order to approach potential respondents, the current research used two survey modes: the paper-based (drop-off) mode (administered through Indochina, a research company) and the web-based (online) mode (administered through the Internet). Furthermore, descriptive and inferential data analysis was performed. In inferential analysis, testing the goodness of the data, including the scales used, was undertaken, prior to hypotheses testing. Chi-square test for independence, independent-samples t-test, exploratory factor analysis (EFA), confirmatory factor analysis (CFA), multivariate analysis of variance (MANOVA), logistic regression, and multiple regression were statistical techniques employed in inferential analysis. CFA was executed by AMOS, whilst the rest were performed by SPSS. Results – This thesis attained 177 usable returned questionnaires, representing the overall response rate to be 47.6%. The results of statistical analyses are as follows. What may prevent fraud? – The first focus. Actual fraud At the model level, the combination of OEC, the effectiveness of OEP, and the effectiveness of OIC, to some extent, significantly predicted actual fraud. Likewise, the combination of the degree of OEP and the degree of OIC, to some extent, significantly predicted actual fraud. Moreover, at the independent variable level, the dimension of supportability under OEC as well as both the degree and effectiveness of OIC make unique statistically significant contributions to predicting/explaining actual fraud. Specifically, the latter is related to the effectiveness of the three dimensions under OIC. They are: management-performed monitoring activities and process-level control activities; commitment-to-competence control environment; and audits-performed monitoring activities and gifts-hospitality control activities. In which, commitment-to-competence control environment made the strongest unique contribution to predicting actual fraud. Conversely, the degree and effectiveness of OEP play no role in mitigating actual fraud. Undetected fraud At the model level, the combination of OEC, the effectiveness of OEP, and the effectiveness of OIC, to some extent, significantly predicted undetected fraud, whilst the combination of the degree of OEP, and the degree of OIC did not. In addition, at the independent variable level, only the dimension of supportability under OEC made a unique statistically significant contribution to predicting undetected fraud, but not the effectiveness and degree of OEP and OIC. Suspected fraud At the model level, the combination of OEC, the effectiveness of OEP, and the effectiveness of OIC, to some extent, significantly predicted suspected fraud, whilst the combination of the degree of OEP, and the degree of OIC did not. Additionally, at the independent variable level, there were three dimensions making unique statistically significant contributions to predicting suspected fraud. They were: the dimension of discussability under OEC, the effectiveness of the dimension of ethics-incorporated performance and employment under OEP, and the effectiveness of the dimension of monitoring activities and process-level control activities under OIC. In which, ethics-incorporated performance and employment made the strongest unique contribution to predicting suspected fraud. Conversely, the degree of OEP and OIC played no role in mitigating suspected fraud. Future fraud At the model level, the combination of OEC, the effectiveness of OEP, and the effectiveness of OIC, to some extent, significantly predicted future fraud, whilst the combination of the degree of OEP, and the degree of OIC did not. Moreover, at the independent variable level, only the dimension of supportability under OEC made a unique statistically significant contribution to predicting future fraud, but not the effectiveness and degree of OEP and OIC. What may contribute to fraud (future only)? – The second focus. For the purposes of this thesis, individual-level determinants (e.g. pressures), organisational-level determinants (e.g. poor OEC, poor OIC), and the industry-level determinant (e.g. the non-profit nature) are micro factors, whilst country-level determinants (e.g. cultural, political, legal, economic, technological) are macro factors. At the model level, the combination of the determinants, to some extent, significantly contributed to engendering future fraud. In addition, at the independent variable level, there were five factors making unique statistically significant contributions to engendering future fraud. They are: two individual-level factors: non-financial personal pressure (e.g. lack of personal discipline, greed) and financial corporate/employment pressure (e.g. management financial interest, low salary); one organisational-level factor: poor OIC; one industry-level factor: the non-profit nature in the operation of INGOs; and one country-level factor: the legal factor in Vietnam. In which, the non-profit nature was the strongest source of future fraud, whilst poor OIC is considered to be a silent source of future fraud. Originality/value – This thesis has made three distinct contributions to the literature. Firstly, it is the first comprehensive study worldwide to incorporate individual-level, organisational-level, industry-level, and country-level factors into predicting future fraud in the INGO/NPO (non-profit organisation) sector in a specific country (e.g. Vietnam), with statistically empirical evidence. Secondly, it is the first comprehensive study worldwide to examine different stages of fraud occurrence (undetected, suspected, actual/detected, and future), with statistically empirical evidence. Thirdly, it is the first comprehensive study in Vietnam as well as in developing countries to investigate fraud in the INGO/NPO sector (industry-level), with statistically empirical evidence. Besides, this thesis also provided other remarkable theoretical contributions. Practical implications – The results of this thesis are useful for different stakeholders in the INGO sector in Vietnam. The results may also be beneficial to stakeholders in the INGO/NPO sectors in other developing countries, which have similar or close national context factors as in Vietnam. The groups of stakeholders include: (1) CEOs, CFOs, CAs and other directors/managers of INGOs; (2) donors of INGOs; (3) auditors related to INGOs; and (4) the Vietnamese government. Furthermore, fruitful areas of further research were identified, in which five research areas, being equivalent to five research projects, could use the data collected by this thesis

CORRUPTION, FRAUD AND INTERNAL CONTROL

The economic crunch created a specific context for activity and profitability failing. The corruption is more and more common in our days. In the same time, the amount of money lost by businesses and the public sector to larger frauds increased last year to unthinkable limits. The shareholders expect the directors to take care to protect their company’s assets. This is why the financial controller has a very important role in each organization. The techniques to detect corruption or a fraud are developing every year. Thus, the introduction of computerized accounting has created the opportunities to conduct very comprehensive tests at relatively little cost. However, the fraudsters became more and more clever, and the controllers are responsible for the prevention and detection of fraud. The procedures that controllers should adopt with regard to fraud depend on the risk that fraud could occur and remain undetected and also the risk of that fraud impairing the truth and fairness of the statement.corruption; fraud; internal control; internal audit; business fraud

HOW TO PREVENT FRAUD?

Fraud can range from minor employee theft and unproductive behavior tomisappropriation of assets and fraudulent financial reporting. The risk of fraud can be reduced through a combination of prevention and detection measures. Moreover, prevention and deterrence measures are much less costly than the time and expense required for fraud detection and investigation. The information presented in this document generally is applicable to entities of all sizes. However, the degree to which certain programs and controls are applied in smaller, less-complex entities and the formality of theirapplication are likely to differ from larger organizations.fraud proofing, fraud prevention, control, accounting analysis, job descriptions, supervision

Pencegahan Kecurangan (Fraud) sesuai dengan Permenkes No. 36 Tahun 2015 tentang Pencegahan Kecurangan (Fraud) dalam Pelaksanaan Program Jaminan Kesehatan pada Sistem Jaminan Sosial Nasional di Rumah Sakit X

Universitas Diponegoro Fakultas Kesehatan Masyarakat Program Studi Magister Ilmu Kesehatan Masyarakat Konsentrasi Administrasi dan Kebijakan Kesehatan 2016 ABSTRAK Lina Umboro Styowati Pencegahan Kecurangan (Fraud) sesuai dengan Permenkes No. 36 Tahun 2015 tentang Pencegahan Kecurangan (Fraud) dalam Pelaksanaan Program Jaminan Kesehatan pada Sistem Jaminan Sosial Nasional di Rumah Sakit X xii + 143 halaman + 8 tabel + 9 gambar +7 lampiran Perubahan pola pembayaran menggunakan CBG menyebabkan perubahan proporsi penerimaan rumah sakit serta perubahan beban resiko keuangan, hal ini yang mendorong timbulnya potensi fraud. Tindakan readmisi di Rumah Sakit X berkisar 29,35% pasien rawat jalan dan 3,6% pasien rawat inap mendapatkan perawatan lebih dari 1 (satu) kali dalam periode 1 (satu) bulan serta belum terciptanya kebijakan pencegahan kecurangan di Rumah Sakit X sebagaimana diamanatkan dalam Permenkes RI No. 36/ 2015. Lima tahapan formulasi dilakukan untuk merumuskan kebijakan, pada penelitian ini hanya melakukan 2 (dua) tahap formulasi yaitu fase pertama berupaya untuk mengidentifikasi tujuan dan program pencegahan kecurangan di Rumah Sakit X dan fase kedua formulasi yaitu menganalisa kelengkapan informasi. Jenis penelitian ini adalah kualitatif dengan menggunakan wawancara dan diskusi mendalam. Informan utama dalam penelitian ini adalah lima koder dan unsur pengambil keputusan. Teknik analisis data dengan analisis konten, meliputi wawancara dengan informan diolah kemudian dilakukan analisis data. Hasil penelitian menunjukkan masih lemahnya pemahaman petugas pelaksana tentang tindakan kecurangan, hal ini ditunjukkan melalui jawaban responden yang memiliki interpretasi berbeda maksud tindakan kecurangan JKN berdasarkan Permenkes No. 36/2015 serta belum adanya atensi dari pengambil keputusan terkait sistem pencegahan. Atensi dapat diketahui dari perhatian utama pengambil kebijakan hanya pada permasalahan pengkodean diagnosa yang memiliki over cost dan juga belum adanya pembaharuan SK Pengendali Asuransi sejak tahun 2013. Untuk mewujudkan sistem pengendalian efektif yang mampu mencegah, melaporkan dan memperbaiki potensi kecurangan di Rumah Sakit X dengan cara menciptakan program pencegahan dan deteksi dini berupa pendidikan anti fraud, investigasi internal melalui analisa data klaim dan program tindakan pelaporan dan pemberian sanksi. Diperlukan kelengkapan sistem berupa tim pencegahan kecurangan dan pedoman pencegahan yang berisi literature review, daftar tindakan yang dianggap potensi fraud, aspek pencegahan, deteksi dan penindakan serta petunjuk teknis pencegahan fraud, monitoring dan evaluasi serta pelaporan. Penelitian ini merekomendasikan untuk menerbitkan SK Tim Pencegahan Kecurangan , merumuskan draf final pencegahan kecurangan agar dapat disahkan menjadi pedoman pencegahan kecurangan, pengembangan sistem informasi untuk analisa data klaim. Kata kunci : Formulasi Kebijakan, Pedoman Pencegahan Kecurangan, Fraud Kepustakaan: 52 (2000-2015) Diponegoro University Faculty of Public Health Master’s Study Program in Public Health Majoring in Administration and Health Policy 2016 ABSTRACT Lina Umboro Styowati Fraud Prevention based on the Health Minister Regulation Number 36 in 2015 about Fraud Prevention in the Implementation of the Health Insurance Program on the National Social Insurance System at X Hospital xii + 143 pages + 8 tables + 9 figures + 7 appendices The change of a payment pattern using CBG causes the change in the proportion of hospital income and the change in burden of financial risk that will lead to fraud. Readmission to X Hospital was approximately 29.35% of patients at outpatient unit and 3.6% of patients at inpatient unit who got treatment more than one in a month. In addition, there was no policy which referred to the Health Minister Regulation Number 36/2015 to prevent fraud at X Hospital. Five steps of formulation were conducted to arrange the policy. In this study, two of these five steps of formulation namely identifying objectives and a program of fraud prevention at X Hospital as the first step and analysing completeness of information as the second step were conducted. This was a qualitative study by conducting indepth interview. Main informants consisted of five coders and decision makers. Data were collected using a method of content analysis. The result of this study showed that the implementers did not really understand fraud activity. Each officer had different interpretation in defining fraud of JKN based on the regulation. In addition, decision makers did not pay attention to this problem. Attention could be identified from the main attention of policy makers that only focussed on a problem of coding diagnosis which had over cost. The Insurance Control Decree have not been renewed since 2013. To realise the effective control system that could prevent, report, and improve a potency of fraud at the X Hospital, it was conducted by creating a program of prevention and early detection like education of anti-fraud, internal investigation through analysing claim data, reporting, and punishing. There needed to complete system like a team of fraud prevention and a prevention guidance that consisted of a literature review, a list of actions categorised as fraud, aspects of prevention, detection, action, a technical guidance of fraud prevention, monitoring, evaluating, and reporting. The Decree of a fraud prevention team needs to be released. A final draft of fraud prevention needs to be arranged in order to be legalised to be a guidance of fraud prevention. In addition, information system needs to be developed to analyse claim data. Keywords : Policy Formulation; Guidance Of Fraud Prevention, Fraud Bibliography: 52 (2000-2015

Accountants’ ethics and fraud control in Nigeria : the emergence of a fraud control model

This paper examined the influence of accountants’ ethics on fraud control. Data were drawn from a review of the literature on ethics and fraud. Using content analysis, major ethical considerations, fraud risk factors, control procedures and the effects of internal control system on fraud detection in Banks were identified. Scholars reached a conclusion in which fraud and fraudulent activities are found to have inflicted severe financial difficulties on Banks and their customers. However, findings indicate that the national value system greatly moderates the extent to which ethics, illustrating from the accountants perspective minimises fraud. Consequently, a fraud control model was developed highlighting the national value system factor in fraud management. The people’s behavioural pattern and philosophy anchored on ethical considerations should reflect honesty, integrity and value of knowledge. This will enhance productivity and good corporate governance. In this manner, fraud will be reduced.peer-reviewe

Analisis Determinan Fraud Prevention (Studi Empiris Pada Badan Usaha Milik Daerah di D.I Yogyakarta dan Jawa Tengah)

This research has a purpose to analyze the influence of proactive fraud audit, whistleblowing system, and internal control system of fraud prevention with morality as a moderating variable. The subject in this research is employees who work in Badan Usaha Milik Daerah (BUMD) in Yogyakarta and Central Java. The number of samples in this research were 70 respondent that has been chosen by using a purposive sampling method. The type of data used is primary data. The results of the research show that proactive fraud audits did not affect fraud prevention. The whistleblowing system has a positive influence on fraud prevention. The internal control system has a positive influence on fraud prevention. Morality strengthens the influence of proactive fraud audits on fraud prevention. Morality does not moderate the influence of the whistleblowing system on fraud prevention. Morality does not moderate the influence of the internal control system on fraud prevention. Keywords: Proactive fraud audit, Whistleblowing System, Internal Control System, Fraud Prevention, Morality. &nbsp

THE FIGHT AGAINST FRAUD AND TAX EVASION IN THE EUROPEAN UNION. THE PROTECTION OF COMMUNITY FINANCIAL INTERESTS IN ROMANIA

The European Union budget is financed by taxes paid by European taxpayers andserves for the development of projects of common interest. The European Community and itsMember States attach great importance to its protection, both in terms of proper collection of taxesand duties and also in terms of proper use of appropriations. This is one of the priorities of theinstitutions involved, as an obligation imposed by the Treaty establishing the EuropeanCommunity. The protection of European Union financial interests involve the detection, controland effective monitorising of fraud and any other illegal acts which result form the misuse of EUfunds and thus prejudicing the Community budget. Cooperation between national authorities andbetween them and EU institutions is a prerequisite for successful fight against fraud. In Romania,national coordinator of the fight against fraud, with responsibilities in control line use ofcommunity funds is European Anti-Fraud Office (OLAF).OLAF, DLAF, European funds, fraud