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Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Book Description

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.

Table of Contents

  1. Cover
  2. Title Page
  3. Copyright
  4. Dedication
  5. Preface
  6. Acknowledgments
  7. Chapter 1: Introduction to Healthcare Fraud
    1. What Is Healthcare Fraud?
    2. Healthcare Fraud in the United States
    3. Healthcare Fraud in International Markets
    4. What Does Healthcare Fraud Look Like?
    5. Who Commits Healthcare Fraud?
    6. What Is Healthcare Fraud Examination?
    7. The Primary Healthcare Continuum: An Overview
    8. Healthcare Fraud Overview: Implications for Prevention, Detection, and Investigation
    9. Notes
  8. Chapter 2: Defining Market Players within the Primary Healthcare Continuum
    1. The Patient
    2. The Provider
    3. The Payer
    4. The Employer/Plan Sponsor
    5. The Vendor and the Supplier
    6. The Government
    7. Organized Crime
    8. Market Players Overview: Implications for Prevention, Detection, and Investigation
  9. Chapter 3: Continuum Audit and Investigative Model
    1. Market Understanding
    2. The Primary Healthcare Continuum (P-HCC)
    3. The Secondary Healthcare Continuum (S-HCC)
    4. The Information Healthcare Continuum (I-HCC)
    5. The Consequence Healthcare Continuum (C-HCC)
    6. The Transparency Healthcare Continuum (T-HCC)
    7. The Rules Based Healthcare Continuum (R-HCC)
    8. Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation
    9. Notes
  10. Chapter 4: Secondary Healthcare Continuum
    1. The Secondary Healthcare Continuum (S-HCC)
    2. Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation
    3. Notes
  11. Chapter 5: Information Healthcare Continuum
    1. Case Study Dr. Traveler—Recap
    2. Continuum Audit Progression—Recap
    3. The Information Healthcare Continuum (I-HCC)
    4. Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation
    5. Notes
  12. Chapter 6: Consequence Healthcare Continuum
    1. Case Study Dr. Traveler—Recap
    2. Continuum Audit Progression—Recap
    3. The Consequence Healthcare Continuum (C-HCC)
    4. Economic Business Impact
    5. Serviceability and Service Integrity
    6. Service, Medical, and Financial Errors
    7. Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation
  13. Chapter 7: Transparency Healthcare Continuum
    1. Case Study Dr. Traveler—Recap
    2. Continuum Audit Progression—Recap
    3. The Transparency Healthcare Continuum (T-HCC)
    4. Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation
  14. Chapter 8: Rules Based Healthcare Continuum
    1. Case Study Dr. Traveler—Recap
    2. The Rules Based Healthcare Continuum (R-HCC)
    3. Continuum Audit Progression—Summary
    4. Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation
    5. Notes
  15. Chapter 9: Protected Health Information
    1. Health Insurance Portability and Accountability Act of 1996
    2. Audit Guidelines in Using Protected Health Information
    3. Protected Health Information Overview: Implications for Prevention, Detection, and Investigation
  16. Chapter 10: Health Information Pipelines
    1. The Auditor's Checklist
    2. What Are the Channels of Communication in a Health Information Pipeline?
    3. Unauthorized Parties
    4. Health Information Pipelines Overview: Implications for Prevention, Detection, and Investigation
  17. Chapter 11: Accounts Receivable Pipelines
    1. Overview of Healthcare Reimbursement
    2. Types of Reimbursement Models
    3. Data Contained in Accounts Receivable Pipelines
    4. Accounts Receivable Pipelines by Healthcare Continuum Player
    5. Accounts Receivable Pipelines Overview: Implications for Prevention, Detection, and Investigation
  18. Chapter 12: Operational Flow Activity
    1. Operational Flow Activity Assessment
    2. Operational Flow Activity Overview: Implications for Prevention, Detection, and Investigation
  19. Chapter 13: Product, Service, and Consumer Market Activity
    1. Product Market Activity
    2. Service Market Activity
    3. Consumer Market Activity
    4. Product, Service, and Consumer Market Activity Overview: Implications for Prevention, Detection, and Investigation
  20. Chapter 14: Data Management
    1. Data Management
    2. Market Example: Setting Up a Claims Relational Database Management System
    3. Data Management Overview: Implications for Prevention, Detection, and Investigation
  21. Chapter 15: Normal Infrastructure
    1. Normal Profile of a Fraudster
    2. Anomalies and Abnormal Patterns
    3. Continuum Audit and Investigative Model
    4. Normal Infrastructure Overview: Implications for Prevention, Detection, and Investigation
  22. Chapter 16: Normal Infrastructure and Anomaly Tracking Systems
    1. The Patient
    2. The Provider
    3. The Payer
    4. The Vendor/Other Parties
    5. Organized Crime
    6. Normal Infrastructure and Anomaly Tracking Systems Overview: Implications for Prevention, Detection, and Investigation
    7. Notes
  23. Chapter 17: Components of the Data Mapping Process
    1. What Is Data Mapping?
    2. Data Mapping Overview: Implications for Prevention, Detection, and Investigation
  24. Chapter 18: Components of the Data Mining Process
    1. What Is Data Mining?
    2. Data Mining Overview: Implications for Prevention, Detection, and Investigation
  25. Chapter 19: Components of the Data Mapping and Data Mining Process
    1. Forensic Application of Data Mapping and Data Mining
    2. Data Mapping and Data Mining Overview: Implications for Prevention, Detection, and Investigation
  26. Chapter 20: Data Analysis Models
    1. Detection Model
    2. Investigation Model
    3. Mitigation Model
    4. Prevention Model
    5. Response Model
    6. Recovery Model
    7. Data Analysis Model Overview: Implications for Prevention, Detection, and Investigation
  27. Chapter 21: Clinical Content Data Analysis
    1. What Is SOAP?
    2. The SOAP Methodology
    3. Electronic Records
    4. Analysis Considerations with Electronic Records
    5. Narrative Discourse Analysis
    6. Clinical Content Analysis Overview: Implications for Prevention, Detection, and Investigation
  28. Chapter 22: Profilers
    1. Fraud and Profilers
    2. Medical Errors and Profilers
    3. Financial Errors and Profilers
    4. Internal Audit and Profilers
    5. Recovery and Profilers
    6. Anomaly and Profilers
    7. Fraud Awareness and Profilers
    8. Profiler Overview: Implications for Prevention, Detection, and Investigation
  29. Chapter 23: Market Implications
    1. The Myth
    2. “Persistent”
    3. “Persuasive”
    4. “Unrealistic”
    5. Market Overview: Implications for Prevention, Detection, and Investigation
  30. Chapter 24: Conclusions
    1. Micromanagement Perspective
    2. Macromanagement Perspective
    3. Overview of Prevention, Detection, and Investigation
  31. About the Author
  32. Index