BHA FPX 4020 Assessment 2 Framework for Analysis

Framework for Analysis

Student Name

Capella University

BHA-FPX 4020

Professor’s Name

Submission Date

An analytical framework should be comprehensive in identifying and responding to healthcare fraud in a home care agency. Such a framework must be premised on a systems-thinking approach, which will assist in revealing the interrelated reasons that facilitate the development of fraudulent actions. The agency can investigate the root causes of the fraud in a systematic manner by using tools such as root cause analysis (RCA) and provide efficient solutions. Also, the analysis should include cultural sensitivity so that different views would be taken into consideration, and teams would work more closely together. This will not only increase the capacity of the agency to detect fraud but also foster long-term solutions with long-term organizational objectives.

Identifying an Appropriate Tool for Analysis of the Selected Healthcare Problem

Root cause analysis is the right instrument to use to examine healthcare fraud in a home care agency. De et al. (2024) state that the emphasis of RCA on systemic problems is essential to ensure that interventions are based on the factors that facilitate fraud and not only respond to the surface-level symptoms. RCA is a methodical system that is utilized to determine the root cause of problems. It is the best system for addressing systemic problems that cause fraud.

RCA assists in the identification of underlying causes of fraud in the healthcare industry, including ineffective training, ineffective policies, or poorly implemented internal controls. RCA enables organizations to take long-term corrective actions that are long-term by detecting these root causes to avoid the recurrence of fraud. The tool has gained a lot of acceptance in the healthcare sector, especially by other agencies such as the Centers for Medicare and Medicaid Services (CMS), because it is effective in dealing with the complications of fraud.

Rationale

The use of RCA in healthcare fraud analysis is especially appropriate because it is a holistic technique. This is supported by the research conducted by Najar et al. (2025), which points out that RCA is a valuable instrument in discovering the underlying problems of healthcare processes and providing a fraud prevention strategy to be an inclusive and sustainable. Not only does it show what has gone wrong, but it also gives information as to why it has allowed it to happen, which is imperative in long-term prevention. RCA helps organizations make the changes at the core of the organization by identifying the systemic failures and implementing the required actions, for instance, enhancing the training of the staff or changes in policies. Other tools, like Pareto charts or control charts, are more for monitoring the symptoms and trends, but do not go into detail about the causes.

Justification for the Recommended Assessment Tool

Root cause analysis is the chosen instrument that will be used to analyze healthcare fraud in a home care agency. RCA is a well-known technique for establishing the root causes of issues, which makes it a powerful option when studying the root causes of healthcare fraud. As per the study by ACCA (2025), RCA is very practical in uncovering systemic problems within the processes, policies, or employee conduct that might support fraud. RCA could be useful in establishing long-term corrective measures to curb fraud as opposed to focusing on symptoms by means of addressing the root causes. That is why RCA can be identified as a good fit for a more focused approach to addressing the problem of fraud: it can assist in revealing systemic issues in healthcare systems, including insufficient staff training, bad data organization, or lax internal controls.

Justification for RCA

RCA is also a useful method of dealing with healthcare fraud, as it can help to determine systemic problems that lead to fraud. Villegas-Ortega et al. (2021) stated that RCA plays a significant role in the healthcare environment, which aims at identifying and remedying the circumstances that enable fraud to flourish. It aims at identifying the causes but not the symptoms, allowing organizations to adopt long-term solutions. RCA assists organizations in enhancing their operations, policies, and employee training so that fraud will not repeat. RCA can help provide a more all-encompassing solution to fraud prevention by getting to the root of the problem, through poor data management or insufficient controls.

Pros and Cons of Tools Not Selected

RCA is best when we are trying to identify the root causes, but other tools have been taken into consideration. The Pareto Chart, though efficient in concentrating on the priority of the problems in the manner of frequency or the financial influence, does not focus on the deep-rooted causes of the problem, which is crucial in addressing the question of healthcare fraud in its all-encompassing manner (Alkiayat, 2021).

Also, we have thought about control charts, but they were discarded because they are more intended to track processes over time and not to examine the root causes of the issue. RCA was preferred to these tools since it enables a better insight into the reasons why the fraud takes place and offers actionable information on the ways of reducing future instances of the fraud, unlike Pareto charts and control charts, which are more useful in identifying and tracking trends but not diagnosing the root causes.

Organizational Context for Resolution

Healthcare fraud in a home care agency is a problem that cannot be effectively handled through an individualistic approach because the problem is usually entrenched in a system of related organizational components. A system approach recognizes that fraud is not an individual action but a phenomenon that is conditioned by a variety of elements within the organization, such as leadership, employee actions, and computer technology (Hassan et al., 2022). The internal processes, policies, training programs, and data management systems of the agency are crucial in facilitating or hindering fraud.

Beginning with the resolution of this problem, the home care agency needs to evaluate all the systems to see the areas that constitute weaknesses that allow the fraud to flourish, including ignorance of staff, inadequate internal controls, or poor auditing habits. This can be solved by reinforcing training programs, revising policies, and improving data analytics to identify anomalies. In addition, developing a culture of accountability and transparency across the organization is important to achieve success in the long term.

The different departments, like compliance, human resources, and finance, should work hand in hand to ensure that the different parts are synchronized in an effort to curb fraud. Recent studies provide evidence in favor of the systems-thinking approach to the problem of the role of organizational factors (policies and training) in fraud (Glynn, 2022). The agency can bring about long-term and structural changes by tackling the problem as a system and blocking future cases of fraud.

Problem-Solving Process

In solving the issue of healthcare fraud in a home care agency, there is a necessity to adopt a culturally sensitive problem-solving process as a measure of getting the buy-in of the interdepartmental team that is diverse. To start with, it is necessary to open a free discussion to all departments, such as compliance, HR, and finance, regarding the issue, keeping in mind the variety of cultures and experiences that could affect their point of view.

The inclusive training based on culture will assist in developing awareness and empowering employees to detect and act against fraud in a manner that is culturally sensitive in terms of communication patterns and values (Villegas-Ortega et al., 2021). It is important to develop a cooperative atmosphere in which everyone can be heard, and each one should be respected and understood.

The second action is the identification of the root causes of fraud by applying a systematic technique, which may be the RCA, so that all members of the team take part in data gathering and analysis. An important aspect is employing culturally acceptable approaches of communication to spread the significance of transparency and accountability. The team can coordinate its efforts by focusing on common objectives and the beneficial outcome of patient care. A culturally sensitive and systems-based approach to the problem would aid in making sure the solutions are sustainable.

Conclusion

The challenge of dealing with healthcare fraud in a home care agency is complex and multidimensional because it involves the need to trace the underlying causes and effect systemic changes. Through the deployment of tools such as the RCA and the development of cultural sensitivity, the organization would be able to increase its fraud prevention efforts and make its work environment more ethical.

Interdepartmental cooperation is a major factor that ensures that every aspect that leads to fraud is considered effectively. The agency will use a systems-thinking approach to find out its weaknesses, increase internal controls, and develop a culture of accountability. Such initiatives will eventually lower fraud but also enhance patient care and integrity in the organization in the long run.