Date of Conferral
5-2-2025
Date of Award
May 2025
Degree
Doctor of Business Administration (D.B.A.)
School
Business Administration
Advisor
William Stokes
Abstract
Medicaid fraud and abuse in health care billing is committed by licensed practitioners, patients, or criminal organizations and can pose a serious business problem. Health care managers are particularly concerned because fraudulent claims can result in lost revenue, legal consequences, and diminished resources for legitimate patient care. Grounded in the Complex Adaptive Systems Model, the purpose of this qualitative pragmatic inquiry was to explore the strategies some health care managers use to reduce fraud and abuse in health care billing. The participants included four health care managers in California who have successfully implemented strategies to mitigate fraud and financial abuse. Data were collected using semistructured interviews and public documents. Through thematic analysis, three themes emerged: (a) feedback-driven assessments and monitoring with the Epic system, (b) following the money trail, and (c) performance reviews and cost-effectiveness. A key recommendation is for health care managers to use feedback from customers and senior managers to refine training programs to ensure that training investments enhance organizational performance and innovation and reduce incidents of fraud and financial abuse. The implications for positive social change include the potential for health care managers to improve job satisfaction and for consumers to experience enhanced care quality and reduced costs through more efficient use of health care resources.
Recommended Citation
NGUYEN, TRAM-ANH LEEZA, "Strategies to Reduce Medicaid Fraud and Abuse in Health Care Billing" (2025). Walden Dissertations and Doctoral Studies. 17687.
https://scholarworks.waldenu.edu/dissertations/17687
