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Fraud and Abuse

Fraud and Abuse

A lot of personal and sensitive information is collected from patients during their interactions with healthcare providers to facilitate care provision and treatment. The Health Insurance Portability and Accountability Act (HIPAA) provides regulatory guidelines that direct healthcare service providers on what to collect regarding health data and information and how to store and use or share such information despite the existence of governing laws and regulations, such collected data may be accessed or disclosed in unauthorized ways, breaching patients’ privacy. The occurrence of privacy breaches and their implications within healthcare settings are unanticipated. Therefore, it is important to explore how such breaches occur from a theoretical perspective to help develop solutions to reduce and prevent such privacy breaches within healthcare settings.


The current health information systems present opportunities in healthcare and concerns over health information safety and privacy (Kaplan, 2020). The current concern in the field of health information is the privacy and safety of the information collected and stored by healthcare providers. Privacy breaches have become common in the current healthcare settings. A privacy breach occurs when healthcare records or information is illegally accessed and disclosed by authorized or unauthorized parties. Privacy breaches within healthcare systems may be intended or unintentional. Intentional privacy breaches occur when a healthcare employee, such as a nurse, accesses unauthorized health information for malicious reasons, while unintentional breaches occur due to poor data protection and privacy measures and unsecured user practices that may result in unintended exposure of private information (Khan et al., 2021). Privacy breaches within healthcare settings, intentional or unintentional, may result from hacking and IT related, such as using stolen credentials, insider mistakes or threats leading to the disclosure of information, loss of information storage devices, and other medical malpractices.

Merton’s Theory of Unanticipated Consequences

The theory of Unanticipated Consequences, usually known as the Unanticipated Consequences of Purposive Social Action, was formulated and popularized by sociologist Robert K. Merton. The theory notes that all results within a situation are exclusively the outcome of purposeful action. Purposeful actions occur at different levels and influence the direction of life in general. The consequences of an action occur as a result of the interaction of that particular action and the intentions of that action (Braidotti & Fuller, 2019). All consequences of a situation emerge due to an act occurring with an intended objective. This means that a result would not occur if an action had been intended to achieve that result. This is the general focus of people in many situations. Attention is paid to the intention of the action and the expected consequences. However, Merton argued that people fail to see or take note of all the consequences of their actions and those that happen beyond their intentions. Purposeful actions have unintended impacts that may have unintended consequences beyond the ones that were desired to occur. Do you need help with your assignment ?

Merton’s Theory of Unanticipated Consequences notes that unintended results from a purposeful action may occur as a result of errors made in problem analysis, interpretation, and interpretation. Having a short-term focus while making long-term decisions may result in unintended outcomes. Merton, in his theory, further identified the use of insufficient methods and values in decision-making, and the fear of taking necessary actions as needed led to unintended outcomes even when actions were purposeful.

Applicability of Merton’s Theory of Unanticipated Consequences in HIPAA and the Consequences of Leadership Inaction in Privacy Breaches

Health law and regulatory bodies on matters of health information privacy, such as the HIPAA, provide the laws, regulations, and guidelines that define the standards of use and disclosure of a patient’s health information. However, privacy breaches occur within healthcare settings such as in facilities. Most such privacy breaches occur as a result of insider threats more than external data privacy threats due to leadership in action. Merton’s Theory of Unanticipated Consequences can be applied in cases related to breach of privacy as a consequence of leadership inaction.

Healthcare leaders are viewed as rational decision-makers whose decisions impact entire facilities, organizations, and the healthcare system. As health leaders, their decisions on policies, behaviors in healthcare settings, and actions regarding health information privacy influence the activeness and effectiveness of measures taken to protect such information. By applying Merton’s theory, it can be well understood how the purposes of the leader’s decisions and actions help achieve the desired outcomes, in this case, the protection of patient health information. On the other hand, leaders can understand the potential effects of their inaction or wrong decisions.

The HIPAA can also apply the theory to understand the mechanisms of action and unanticipated consequences and differentiate whether actions that lead to privacy breaches are intentional or unintentional. Merton distinguished between conduct and behavior. It is in this understanding that it can be noted that an individual’s purposive action or conduct does not relate to their behaviors. Other factors are at play for such conduct to be displayed. Leadership inaction leading to the privacy breach may be influenced by factors beyond the leaders’ behavior or conduct. Inaction may occur as a result of barriers related to resources and data. Intentional and unintentional inaction leading to privacy breaches may be observed from a perspective of motives, the source of the motives, and decisions made at the time of the privacy breach.

Intentional inaction and privacy breaches are motivated and result from a purposeful action taken. On the other hand, from the perspective of Morten’s Theory of Unanticipated Consequences, unintentional data breaches may occur without a clear purpose or lack of awareness of the consequences of actions during the time and point of the breach. Such unintentional privacy breaches may result from ignorance, lack of knowledge and experience, and inadequate examination of a situation before deciding on an action.

Implications, Examples, and Solutions

Consequences of HIPPA Privacy Breach

The consequences of the HIPAA privacy breach affect both the violators and those impacted by the beach. The breaches may result in health information exposure, leading to unanticipated social and health outcomes. The consequences of the HIPAA privacy breaches on the violators depend on the nature of the violation of HIPAA regulations, knowledge of HIPAA rules, the magnitude of the violation, the intention of the privacy breach, and the harm caused by the violation. If warranted, HIPAA privacy breaches can lead to civil penalties, including fines, operating licensure termination, credibility loss, and professional sanctions. The privacy breaches can also result in criminal charges resulting in a jail term and heavy fines.

Examples of Privacy Breaches in Healthcare

Two leading examples of privacy breaches in health include the cases of Florida Healthy Kids Corporation in 2021, in which 3.5 million individuals were affected, and the Forefront Dermatology incident in 2021, in which over 2.4 million individuals, including patients and workers, were affected (Jercich, 2021).

Provisions of HIPAA Related to Privacy Breaches

The HIPAA’s major provision related to privacy breaches is the privacy rule. The privacy rule was formulated and designed to protect individual health information collected, shared, stored, and used in health care in any form. Healthcare situations require patients to provide physicians and other healthcare service providers with personal information, including their health history, drug use, lifestyle, and feelings. The HIPAA requires health providers to keep all that information private unless permissible by the governing laws to share it. The law requires that all patient health information and medical records be kept private in all healthcare settings.


Health information is important for the development of patient-centered care. However, such information is threatened by data breaches that impact the privacy of the health information collected and stored in healthcare settings. The HIPAA has various provisions that guide the protection and safety of healthcare information. The case for breach of privacy may be intentional or unintentional. Privacy breaches are a result of purposeful action; however, such actions are differentiated by their intentions and motives. The HIPAA can apply Morten’s Theory of Unanticipated Consequences to understand the mechanisms of privacy breaches in relation to action and intentions.


Braidotti, R., & Fuller, M. (2019). The posthumanities in an era of unexpected consequences. Theory, Culture & Society, 36(6), 3-29.

Jercich, K. (2021). The biggest healthcare data breaches of 2021. Healthcare IT News. Retrieved 5 May 2022, from

Kaplan, B. (2020). Seeing through health information technology: the need for transparency in software, algorithms, data privacy, and regulation. Journal of Law and the Biosciences7(1), lsaa062.

Khan, F., Kim, J. H., Mathiassen, L., & Moore, R. (2021). Data breach management: An integrated risk model. Information & Management, 58(1), 103392.


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Fraud and Abuse

Fraud and Abuse

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