Healthcare Fraud: Auditing and Detection Guide / Edition 1

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Overview

Praise for Healthcare Fraud

"Rebecca Busch has taken the cumbersome and complex subject of healthcare fraud and dissected it into well-defined parts. Her thoughtful discussion of how and where these parts provide opportunities for fraud—and how to detect and prevent it—is the essence of this work. This book is a must read for anyone involved in the prevention, detection, and investigation of healthcare fraud."

Robert M. Bryant President and Chief Executive Officer, National Insurance Crime Bureau

"Fraud continues to be a major subject area for internal auditors. Recent studies by the IIA show that healthcare audits are in the top ten subject areas audited. This book speaks to the necessary background that internal auditors should have when auditing healthcare activities so that they can have the necessary skills to look for and deal with potential fraudulent situations. I recommend this book be part of every internal audit department's library."

Dave Richards, CIA, CPAPresident, The Institute of Internal Auditors

"The cost of healthcare fraud continues to escalate each year. It is a terrible burden on our already fragile healthcare system. This book will provide anti-fraud professionals with a valuable resource to help combat this critical problem."

James D. Ratley, CFEPresident, Association of Certified Fraud Examiners

"Rebecca Busch's Healthcare Fraud: Auditing and Detection Guide fills a critical gap in anti-fraud literature. Written professionally and precisely, yet eminently readable, this book will be the 'go to' source for managers, academics, attorneys, auditors, and fraud examiners involved in healthcare. Healthcare Fraud: Auditing and Detection Guide demonstrates Ms. Busch's expertise and depth of knowledge in the area of healthcare fraud, and is testimony as to why she is such a sought-after speaker and educator."

William J. Kresse, MS, JD, CPA, CFEAssistant Professor, Saint Xavier UniversityGraham School of Management2007 ACFE Educator of the Year

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Product Details

  • ISBN-13: 9780470127100
  • Publisher: Wiley, John & Sons, Incorporated
  • Publication date: 12/4/2007
  • Edition description: Older Edition
  • Edition number: 1
  • Pages: 304
  • Product dimensions: 6.46 (w) x 9.15 (h) x 1.06 (d)

Meet the Author

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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Table of Contents

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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