Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Chapter 6

Consequence Healthcare Continuum

The devil is never in the choices we make but in their consequences.

–Anonymous

Does anybody ever really think about doing something they know is wrong with the intent of getting caught? I have not. The recipe for a fraud may include the target, the facilitators, the victims, and a well-defined methodology. The methodology outlines the presentation of the false claim, the claim’s submission, and the collection of the illicit funds. This may, of course, be followed with distribution of these ill-gotten gains and a repetition of the fraudulent activity, which may include modification of the scheme. I have yet to see a scenario with the final component, “…and this is when we will get caught.” Every well-intentioned fraudster enters into a scenario with the true belief and intention of not getting caught. This is when the power of denial really comes into play, along with every toxic effect of the greed that materializes with the benefits of those dollars. As we progress in the use of this continuum audit model, a measurement of damages is important in fully appreciating impact.