Healthcare Fraud
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Healthcare Fraud : Auditing and Detection Guide

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An invaluable tool equipping healthcare professionals, auditors, and investigators to detect every kind of healthcare fraud
According to private and public estimates, billions of dollars are lost per hour to healthcare waste, fraud, and abuse. A must-have reference for auditors, fraud investigators, and healthcare managers, Healthcare Fraud, Second Edition 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.




Includes new chapters on primary healthcare, secondary healthcare, information/data management and privacy, damages/risk management, and transparency
Offers comprehensive guidance on auditing and fraud detection for healthcare providers and company healthcare plans
Examines the necessary background that internal auditors should have when auditing healthcare activities


Managing the risks in healthcare fraud requires an understanding of how the healthcare system works and where the key risk areas are. With health records now all being converted to electronic form, the key risk areas and audit process are changing. Read Healthcare Fraud, Second Edition and get the valuable guidance you need to help combat this critical problem.
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Product details

  • Hardback | 368 pages
  • 157.48 x 231.14 x 35.56mm | 566.99g
  • New York, United States
  • English
  • 2nd Edition
  • 1118179803
  • 9781118179802
  • 1,881,490

Flap copy

Healthcare Fraud Auditing and Detection Guide



The world of healthcare fraud is much more than just pocketing money or a corporate asset. Stealing the very essence of human life, healthcare fraud ranges from false claims by perpetrators who perform needless procedures that disable and kill, to rogue Internet pharmacies. Once limited to petty thefts and deliberately incorrect billing, the world of healthcare fraud has become one of high-tech, highly skilled, educated, and professional perpetrators.



Now completely updated, this Second Edition of Healthcare Fraud: Auditing and Detection Guide is the must-have reference for auditors, fraud investigators, and healthcare managers, revealing proven tips and techniques to help you spot the "red flags" of fraudulent activity, as well as the steps you need to take when fraud is suspected. Author Rebecca Busch--a pioneer in conducting technology and process-enabled audits of healthcare claims and processing--presents comprehensive guidance on auditing and fraud detection for healthcare providers and company healthcare plans.



Healthcare Fraud, Second Edition features:



Six new chapters detailing a comprehensive audit model encompassing primary, secondary, information, damages, transparency, and rules-based continuum. Detailed analytic pipelines within each continuum extrapolating components of PHI, dollars involved, operations, products, services, and type of consumer. This integration is the secret sauce to any successful investigation.



How data mapping and mining can be used as a key tool to maximize the effectiveness of fraud investigations



Insightful discussion from a number of perspectives; clinical, research, internal audit, investigative, data intelligence, and forensic



A behind-the-scenes look at internal controls and anomaly tracking systems for ongoing monitoring and surveillance



Building blocks for understanding the entire healthcare market and its respective players



Cases and methodologies providing actual audit and investigative tools



Useful outlines of healthcare fraud prevention, detection, and investigation methods



Sharpen your skills as an auditor or investigator to identify incontrovertible truth with the visionary guidance found in Healthcare Fraud, Second Edition.
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Back cover copy

HEALTHCARE FRAUD Auditing and Detection Guide, Second Edition

The world of healthcare fraud is much more than just pocketing money or a corporate asset. Stealing the very essence of human life, healthcare fraud ranges from false claims by perpetrators who perform needless procedures that disable and kill, to rogue Internet pharmacies. Once limited to petty thefts and deliberately incorrect billing, the world of healthcare fraud has become one of high-tech, highly skilled, educated, and professional perpetrators.

Now completely updated, this Second Edition of Healthcare Fraud: Auditing and Detection Guide is the must-have reference for auditors, fraud investigators, and healthcare managers, revealing proven tips and techniques to help you spot the "red flags" of fraudulent activity, as well as the steps you need to take when fraud is suspected. Author Rebecca Busch--a pioneer in conducting technology and process-enabled audits of healthcare claims and processing--presents comprehensive guidance on auditing and fraud detection for healthcare providers and company healthcare plans.

Healthcare Fraud, Second Edition features: Six new chapters detailing a comprehensive audit model encompassing primary, secondary, information, damages, transparency, and rules-based continuum. Detailed analytic pipelines within each continuum extrapolating components of PHI, dollars involved, operations, products, services, and type of consumer. This integration is the secret sauce to any successful investigation. How data mapping and mining can be used as a key tool to maximize the effectiveness of fraud investigations Insightful discussion from a number of perspectives; clinical, research, internal audit, investigative, data intelligence, and forensic A behind-the-scenes look at internal controls and anomaly tracking systems for ongoing monitoring and surveillance Building blocks for understanding the entire healthcare market and its respective players Cases and methodologies providing actual audit and investigative tools Useful outlines of healthcare fraud prevention, detection, and investigation methods

Sharpen your skills as an auditor or investigator to identify incontrovertible truth with the visionary guidance found in Healthcare Fraud, Second Edition.
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Table of contents

Preface xiii


Acknowledgments xvii


CHAPTER 1 Introduction to Healthcare Fraud 1


What Is Healthcare Fraud? 2


Healthcare Fraud in the United States 4


Healthcare Fraud in International Markets 4


What Does Healthcare Fraud Look Like? 5


Who Commits Healthcare Fraud? 9


What Is Healthcare Fraud Examination? 11


The Primary Healthcare Continuum: An Overview 13


Healthcare Fraud Overview: Implications for Prevention, Detection, and Investigation 14


Notes 17


CHAPTER 2 Defining Market Players within the Primary Healthcare Continuum 19


The Patient 19


The Provider 24


The Payer 42


The Employer/Plan Sponsor 48


The Vendor and the Supplier 49


The Government 50


Organized Crime 51


Market Players Overview: Implications for Prevention, Detection, and Investigation 53


CHAPTER 3 Continuum Audit and Investigative Model 57


Market Understanding 58


The Primary Healthcare Continuum (P-HCC) 58


The Secondary Healthcare Continuum (S-HCC) 58


The Information Healthcare Continuum (I-HCC) 62


The Consequence Healthcare Continuum (C-HCC) 63


The Transparency Healthcare Continuum (T-HCC) 65


The Rules Based Healthcare Continuum (R-HCC) 66


Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation 68


Notes 68


CHAPTER 4 Secondary Healthcare Continuum 69


The Secondary Healthcare Continuum (S-HCC) 71


Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation 75


Notes 75


CHAPTER 5 Information Healthcare Continuum 77


Case Study Dr. Traveler Recap 77


Continuum Audit Progression Recap 78


The Information Healthcare Continuum (I-HCC) 78


Audit Continuum Models Overview: Implications


for Prevention, Detection, and Investigation 83


Notes 84


CHAPTER 6 Consequence Healthcare Continuum 85


Case Study Dr. Traveler Recap 85


Continuum Audit Progression Recap 86


The Consequence Healthcare Continuum (C-HCC) 86


Economic Business Impact 88


Serviceability and Service Integrity 89


Service, Medical, and Financial Errors 90


Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation 90


CHAPTER 7 Transparency Healthcare Continuum 93


Case Study Dr. Traveler Recap 93


Continuum Audit Progression Recap 94


The Transparency Healthcare Continuum (T-HCC) 95


Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation 96


CHAPTER 8 Rules Based Healthcare Continuum 97


Case Study Dr. Traveler Recap 98


The Rules Based Healthcare Continuum (R-HCC) 99


Continuum Audit Progression Summary 104


Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation 106


Notes 107


CHAPTER 9 Protected Health Information 109


Health Insurance Portability and Accountability Act of 1996 109


Audit Guidelines in Using Protected Health Information 110


Protected Health Information Overview: Implications for Prevention, Detection, and Investigation 113


CHAPTER 10 Health Information Pipelines 115


The Auditor s Checklist 115


What Are the Channels of Communication in a Health Information Pipeline? 116


Unauthorized Parties 125


Health Information Pipelines Overview: Implications for Prevention, Detection, and Investigation 126


CHAPTER 11 Accounts Receivable Pipelines 129


Overview of Healthcare Reimbursement 130


Types of Reimbursement Models 131


Data Contained in Accounts Receivable Pipelines 135


Accounts Receivable Pipelines by Healthcare Continuum Player 135


Accounts Receivable Pipelines Overview: Implications for Prevention, Detection, and Investigation 154


CHAPTER 12 Operational Flow Activity 157


Operational Flow Activity Assessment 157


Operational Flow Activity Overview: Implications for Prevention, Detection, and Investigation 163


CHAPTER 13 Product, Service, and Consumer Market Activity 165


Product Market Activity 165


Service Market Activity 167


Consumer Market Activity 167


Product, Service, and Consumer Market Activity Overview: Implications for Prevention, Detection, and Investigation 175


CHAPTER 14 Data Management 177


Data Management 177


Market Example: Setting Up a Claims Relational Database Management System 181


Data Management Overview: Implications for Prevention, Detection, and Investigation 182


References 182


CHAPTER 15 Normal Infrastructure 185


Normal Profile of a Fraudster 185


Anomalies and Abnormal Patterns 188


Continuum Audit and Investigative Model 188


Normal Infrastructure Overview: Implications for Prevention, Detection, and Investigation 189


CHAPTER 16 Normal Infrastructure and Anomaly Tracking Systems 191


The Patient 191


The Provider 194


The Payer 198


The Vendor/Other Parties 201


Organized Crime 205


Normal Infrastructure and Anomaly Tracking Systems Overview: Implications for Prevention, Detection, and Investigation 207


Notes 207


CHAPTER 17 Components of the Data Mapping Process 209


What Is Data Mapping? 209


Data Mapping Overview: Implications for Prevention, Detection, and Investigation 213


CHAPTER 18 Components of the Data Mining Process 215


What Is Data Mining? 215


Data Mining Overview: Implications for Prevention, Detection, and Investigation 219


CHAPTER 19 Components of the Data Mapping and Data Mining Process 221


Forensic Application of Data Mapping and Data Mining 224


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


and Investigation 226


CHAPTER 20 Data Analysis Models 227


Detection Model 227


Investigation Model 230


Mitigation Model 233


Prevention Model 235


Response Model 240


Recovery Model 244


Data Analysis Model Overview: Implications for Prevention, Detection, and Investigation 253


CHAPTER 21 Clinical Content Data Analysis 255


What Is SOAP? 256


The SOAP Methodology 257


Electronic Records 270


Analysis Considerations with Electronic Records 273


Narrative Discourse Analysis 277


Clinical Content Analysis Overview: Implications for Prevention, Detection, and Investigation 284


CHAPTER 22 Profilers 287


Fraud and Profilers 287


Medical Errors and Profilers 291


Financial Errors and Profilers 296


Internal Audit and Profilers 300


Recovery and Profilers 302


Anomaly and Profilers 303


Fraud Awareness and Profilers 304


Profiler Overview: Implications for Prevention, Detection, and Investigation 305


CHAPTER 23 Market Implications 307


The Myth 307


Persistent 310


Persuasive 310


Unrealistic 312


Market Overview: Implications for Prevention, Detection, and Investigation 313


CHAPTER 24 Conclusions 315


Micromanagement Perspective 315


Macromanagement Perspective 326


Overview of Prevention, Detection, and Investigation 327


About the Author 333


Index 335
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About Rebecca S. Busch

REBECCA SALTIEL BUSCH, RN, MBA, CCM, CFE, CHS-III, CPC, FHFMA, FIALCP, has a passion to create educated, conscientious healthcare consumers. Recent leadership and professional recognitions include the 2011 Chicago United's Business Leaders of Color Award, 2010 Finalist for the Enterprising Women of the Year Award, and 2009 Recipient of the Influential Women in Business Award by the Business Ledger in partnership with NAWBO. Her entrepreneurial, professional, driven career has resulted in various proprietary audit platforms in multi-market verticals in healthcare, and authorship of over 200 articles, books, and presentations to consumers, government, corporate, and professional entities. Recognized as an expert in her field, she has provided public and forensic expert testimony and participated in public policy discussions and the development of best practice standards. Rebecca currently has seven U.S. design patents and one U.S patent focused on efficacy, risk, FWB, and revenue management within healthcare.
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