Healthcare Fraud: Auditing and Detection Guide / Edition 2

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Overview

Healthcare Fraud Auditing and Detection Guide

The world of healthcare fraud is much more than just pocketingmoney or a corporate asset. Stealing the very essence of humanlife, healthcare fraud ranges from false claims by perpetrators whoperform needless procedures that disable and kill, to rogueInternet pharmacies. Once limited to petty thefts and deliberatelyincorrect billing, the world of healthcare fraud has become one ofhigh-tech, highly skilled, educated, and professionalperpetrators.

Now completely updated, this Second Edition of Healthcare Fraud:Auditing and Detection Guide is the must-have reference forauditors, fraud investigators, and healthcare managers, revealingproven tips and techniques to help you spot the "red flags" offraudulent activity, as well as the steps you need to take whenfraud is suspected. Author Rebecca Busch—a pioneer inconducting technology and process-enabled audits of healthcareclaims and processing—presents comprehensive guidance onauditing and fraud detection for healthcare providers and companyhealthcare plans.

Healthcare Fraud, Second Edition features:

  • Six new chapters detailing a comprehensive audit modelencompassing primary, secondary, information, damages,transparency, and rules-based continuum. Detailed analyticpipelines within each continuum extrapolating components of PHI,dollars involved, operations, products, services, and type ofconsumer. This integration is the secret sauce to any successfulinvestigation.
  • How data mapping and mining can be used as a key tool tomaximize the effectiveness of fraud investigations
  • Insightful discussion from a number of perspectives; clinical,research, internal audit, investigative, data intelligence, andforensic
  • A behind-the-scenes look at internal controls and anomalytracking systems for ongoing monitoring and surveillance
  • Building blocks for understanding the entire healthcare marketand its respective players
  • Cases and methodologies providing actual audit and investigativetools
  • Useful outlines of healthcare fraud prevention, detection, andinvestigation methods

Sharpen your skills as an auditor or investigator to identifyincontrovertible truth with the visionary guidance found inHealthcare Fraud, Second Edition.

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Product Details

  • ISBN-13: 9781118179802
  • Publisher: Wiley
  • Publication date: 5/1/2012
  • Edition number: 2
  • Pages: 340
  • Sales rank: 489,930
  • Product dimensions: 6.20 (w) x 9.10 (h) x 0.90 (d)

Meet the Author

Rebecca Saltiel Busch, RN, MBA, CCM, CFE, CHS-III, CPC, FHFMA,FIALCP, has a passion to create educated, conscientious healthcareconsumers. Recent leadership and professional recognitions includethe 2011 Chicago United's Business Leaders of Color Award, 2010Finalist for the Enterprising Women of the Year Award, and 2009Recipient of the Influential Women in Business Award by theBusiness Ledger in partnership with NAWBO. Her entrepreneurial,professional, driven career has resulted in various proprietaryaudit platforms in multi-market verticals in healthcare, andauthorship of over 200 articles, books, and presentations toconsumers, government, corporate, and professional entities.Recognized as an expert in her field, she has provided public andforensic expert testimony and participated in public policydiscussions and the development of best practicestandards.??Rebecca currently has seven U.S. design patents and oneU.S patent focused on efficacy, risk, FWB, and revenue managementwithin healthcare.

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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 PrimaryHealthcare 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 1996109

Audit Guidelines in Using Protected Health Information 110

Protected Health Information Overview: Implications forPrevention, Detection, and Investigation 113

CHAPTER 10 Health Information Pipelines 115

The Auditor’s Checklist 115

What Are the Channels of Communication in a Health InformationPipeline? 116

Unauthorized Parties 125

Health Information Pipelines Overview: Implications forPrevention, 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 Player135

Accounts Receivable Pipelines Overview: Implications forPrevention, 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 Activity165

Product Market Activity 165

Service Market Activity 167

Consumer Market Activity 167

Product, Service, and Consumer Market Activity Overview:Implications for  Prevention, Detection, and Investigation175

CHAPTER 14 Data Management 177

Data Management 177

Market Example: Setting Up a Claims Relational DatabaseManagement 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 Systems191

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 MiningProcess 221

Forensic Application of Data Mapping and Data Mining 224

Data Mapping and Data Mining Overview: Implications forPrevention, 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, andInvestigation 305

CHAPTER 23 Market Implications 307

The Myth 307

“Persistent” 310

“Persuasive” 310

“Unrealistic” 312

Market Overview: Implications for Prevention, Detection, andInvestigation 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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