Healthcare Fraud; Auditing and Detection Guide

An invaluable tool equipping healthcare professionals, auditors, and investigators to detect every kind of healthcare fraudAccording to private and public estimates, billions of dollars are lost per hour to healthcare waste, fraud, and abuse. A must-have… (More)

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What Is Healthcare Fraud?
Healthcare Fraud in the United States
Healthcare Fraud in International Markets
What Does Healthcare Fraud Look Like?
Who Commits Healthcare Fraud?
What Is Healthcare Fraud Examination?
The Primary Healthcare Continuum: An Overview
The Patient
The Provider
The Payer
The Employer/Plan Sponsor
Who Is the Employer/Plan Sponsor?
The Vendor and the Supplier
The Government
Organized Crime
Market Understanding
The Primary Healthcare Continuum (P-HCC)
The Secondary Healthcare Continuum (S-HCC)
The Information Healthcare Continuum (I-HCC)
The Transparency Healthcare Continuum (T-HCC)
The Rules Based Healthcare Continuum (R-HCC)
Notes
Case Study Dr. Traveler—Recap
Continuum Audit Progression—Recap
The Consequence Healthcare Continuum (C-HCC)
Economic Business Impact
Serviceability and Service Integrity
Service, Medical, and Financial Errors
EXHIBIT 7.1 Transparency Healthcare Continuum (T-HCC)
Continuum Audit Progression—Summary
Auditor’s Checklist
UnauthorizedParties
Overview of Healthcare Reimbursement
Types of Reimbursement Models
Data Contained in Accounts Receivable Pipelines
Operational Flow Activity Assessment
Data Management
References
Normal Proﬁle of a Fraudster
Anomalies and Abnormal Patterns
Continuum Audit and Investigative Model
The Vendor/Other Parties
What Is Data Mapping?
What Is Data Mining?
DetectionModel
InvestigationModel
MitigationModel
Prevention Model
ResponseModel
RecoveryModel
What Is SOAP?
The SOAP Methodology
Electronic Records
Analysis Considerations with Electronic Records
Narrative Discourse Analysis
Fraud and Proﬁlers
Medical Errors and Proﬁlers
Financial Errors and Proﬁlers
Internal Audit and Proﬁlers
Recovery and Proﬁlers
Anomaly and Proﬁlers
Fraud Awareness and Proﬁlers
The Myth
“Persistent”
“Persuasive”
“Unrealistic”
Micromanagement Perspective
Macromanagement Perspective
Overview of Prevention, Detection, and Investigation
About the Author
Index

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03/30/2012

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9781118227220

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