Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Chapter 7

Transparency Healthcare Continuum

Transparency is not the same as looking straight through a building: it’s not just a physical idea; it’s also an intellectual one.

–Helmut Jahn, architect (1940–)

Transparency is, simply put, the state of being transparent. What does this really mean? Transparent is the ability to see through, understand, and recognize information. Why is such a simple concept so complex in healthcare? We can see a doctor taking care of a patient—this is a physical idea, one that is easily understood. The care is followed by a “bill” that is submitted to a third party, and the terms of reimbursement are applied against a set of rules by yet another fourth party. Within government-sponsored programs, such as Medicare and Medicaid, these rules are public, although complicated; they are available.

In the private sector, contracts between third and fourth parties are considered proprietary; they are not transparent or readily available. What this means is that some parties will have limited access to information. The components in which one does not have access would require an intellectual connection with the application of certain assumptions. This is among known parties. However, it is also necessary to understand and recognize that you may have unknown parties with critical information. The level of risk is directly proportional to the amount of information that is known to be limited and to information that is not known at all. In this chapter, we highlight ...