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Healthcare Fraud: Auditing and Detection Guide

ISBN: 978-0-470-22708-4
320 pages
March 2008
Healthcare Fraud: Auditing and Detection Guide (0470227087) cover image
According to private and public estimates, approximately $24 million is lost per hour to healthcare waste, fraud, and abuse. A must-have reference for auditors, fraud investigators, and healthcare managers, Healthcare Fraud: Auditing and Detection Guide provides tips and techniques to help you spot—and prevent—the "red flags" of fraudulent activity within your organization. Eminently readable, it is your “go-to” resource, equipping you with the necessary skills to look for and deal with potential fraudulent situations.
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Chapter 1. Introduction To Healthcare Fraud.

What Is Healthcare Fraud?

What Does Healthcare Fraud Look Like?

Healthcare Fraud in the United States.

Healthcare Fraud in International Markets.

Who Commits Healthcare Fraud?

What Is Healthcare Fraud Examination?

The Healthcare Continuum: An Overview.

Healthcare Fraud Overview: Implications for Prevention, Detection, and Investigation.

Chapter 2. Defining Market Players Within The Healthcare Continuum.

The Patient.

Who Is the Patient?

What Are Some Examples of Patient Fraud?

How Does the Patient Role Relate to Other Healthcare Continuum Players?

The Provider.

Who Is the Provider?

What Are Some Examples of Provider Fraud?

How Does the Provider Role Relate to Other Healthcare Continuum Players?

The Payer.

Who Is the Payer?

What Are Some Examples of Payer Fraud?

How Does the Payer Role Relate to Other Healthcare Continuum Players?

The Employer/Plan Sponsor

Who Is the Employer/Plan Sponsor?

What Are Some Examples of Employer/Plan Sponsor Fraud?

How Does the Employer/Plan Sponsor Role Relate to Other Healthcare Continuum Players?

The Vendor and the Supplier.

Who Are the Vendor and the Supplier?

What Are Some Examples of Vendor and Supply Fraud?

How Do the Vendor and Supplier Roles Relate to Other Healthcare Continuum Players?

The Government.

Who Is the Government?

What Are Some Examples of Government Fraud?

How Does the Government Role Relate to Other Healthcare Continuum Players?

Organized Crime.

Who Is Organized Crime?

How Does the Organized Crime Role Relate to Other Healthcare Continuum Players?

Market Players Overview: Implications for Prevention, Detection, and Investigation.

Chapter 3. Protected Health Information.

Health Insurance Portability and Accountability Act of 1996.

Audit Guidelines in Using PHI.

Protected Health Information Overview: Implications for Prevention, Detection, and Investigation.

Chapter 4. Health Information Pipelines.

The Auditor's Checklist.

What Are the Channels of Communication in a Health Information Pipeline?

The Patient.

The Provider.

The Payer.

The Employer/Plan Sponsor.

The Vendor/Supplier.

The Government Plan Sponsor.

Unauthorized Parties.

HIP Overview: Implications for Prevention, Detection, and Investigation

Chapter 5. Accounts Receivable Pipelines.

Overview of Healthcare Reimbursement.

Types of Reimbursement Models.

Fee for Service Model.

Prospective Model.

Capitation-Structured Model.

Data Contained in Accounts Receivable Pipelines.

Accounts Receivable Pipelines by HCC Player.

The Patient.

The Provider.

The Payer.

The Employer/Plan Sponsor.

Others.

ARP Overview: Implications for Prevention, Detection, and Investigation.

Chapter 6. Operational Flow Activity.

Operational Flow Activity.

The Patient.

The Provider.

The Payer.

The Employer.

The "Other".

OFA Overview: Implications for Prevention, Detection, and Investigation.

Chapter 7. Product, Service, And Consumer Market Activity.

Product Market Activity.

Service Market Activity.

Consumer Market Activity.

PMA, SMA, CMA Overview: Implications for Prevention, Detection, and Investigation.

Chapter 8. Data Management.

Data Management.

Market Example: Setting Up a Claims RDBMS.

Data Management Overview: Implications for Prevention, Detection, and Investigation.

References.

Chapter 9. Normal Infrastructure.

Normal Profile of a Fraudster.

What Types of People or Entities Commit Fraud?

What Is the Key Element of a Fraudster?

Anomalies and Abnormal Patterns.

Normal Infrastructure Overview: Implications for Prevention, Detection, and Investigation.

Chapter 10. Normal Infrastructure And Anomaly Tracking Systems.

The Patient.

Sample Patient Fraud Scenarios.

Patient Data Management Considerations.

The Untold Story.

The Provider.

Sample Provider Fraud Scenarios.

Provider Data Management Considerations.

The Untold Story.

The Payer.

Sample Payer Fraud Scenarios.

Data Management Implications.

The Untold Story.

The Vendor/Other Parties.

Sample Vendor/Other Fraud Scenarios.

Data Management Implications.

The Untold Story.

Organized Crime.

Sample Organized Crime Fraud Scenarios.

Data Management Implications.

The Untold Story.

Normal Infrastructure and Anomaly Tracking Systems Overview: Implications for Prevention, Detection, and Investigation.

Chapter 11. Components To The Data Mapping Process.

What Is Data Mapping?

Data Mapping Overview: Implications for Prevention, Detection, and Investigation.

Chapter 12. Components To The Data Mining Process.

What Is Data Mining?

Data Mining in Healthcare.

Components to the Data Mining Process within the HCC.

Data Mining Overview: Implications for Prevention, Detection, and Investigation.

Chapter 13. Components To The Data Mapping And Mining Process.

Forensic Application of Data Mapping and Data Mining.

Data Mapping and Data Mining Overview: Implications for Prevention, Detection, and Investigation.

Chapter 14. Data Analysis Models.

Detection Model.

Pipeline Application.

Detection Model Application.

Investigation Model.

Mitigation Model.

Prevention Model.

Independent Medical Examiner Practices for Ten Years without a Medical Degree.

Response Model.

Recovery Model.

Data Analysis Model Overview: Implications for Prevention, Detection, and Investigation.

Chapter 15. Clinical Content Data Analysis.

What Is SOAP?

The SOAP Methodology.

Electronic Records.

Analysis Considerations with Electronic Records.

Narrative Discourse Analysis.

Clinical Content Analysis Overview: Implications for Prevention, Detection, and Investigation.

Chapter 16. Profilers.

Fraud and Profilers.

Medical Errors and Profilers.

Financial Errors and Profilers.

Internal Audit and Profilers.

Recovery and Profilers.

Anomaly and Profilers.

Fraud Awareness and Profiler.

Profiler Overview: Implications for Prevention, Detection, and Investigation.

Chapter 17. Market Implications.

The Myth.

"Persistent".

"Persuasive".

"Unrealistic".

Market Overview: Implications for Prevention, Detection, and Investigation.

Chapter 18. Conclusions.

Micromanagement Perspective.

Macromanagement Perspective.

Overview of Prevention, Detection, and Investigation.

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Rebecca S. Busch, RN, MBA, CCM, CBM, CHS-III, CFE, FHFMA, is President and CEO of Medical Business Associates, Inc., a consulting firm specializing in healthcare audits for employers, hospitals, and insurance companies. She has over twenty years of achievement in the healthcare management industry. She is a faculty member of the Association of Certified Fraud Examiners (ACFE), has published numerous articles, and is a frequent public speaker.

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