Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Chapter 22

Profilers

Always tell the truth. That way, you don’t have to remember what you said.

–Mark Twain (1835–1910)

Profilers are the descriptions of behavioral characteristics and traits of data elements noted during a series of referential comparisons. Referential analysis is the comparison of a data element to a specified context. This chapter provides a series of profilers that can be used throughout the primary healthcare continuum (P-HCC) during a specific audit or investigation. As noted in the prior chapters, attributes of the remaining continuums do apply (secondary healthcare continuum [S-HCC], information healthcare continuum [I-HCC], consequence healthcare continuum [C-HCC], the transparency healthcare continuum [T-HCC], and the rules based healthcare continuum [R-HCC].) Please note, this chapter will illustrate the use of the profiler models by applying the attributes of the P-HCC. In each example, issues with benchmarks, information systems, consequences, transparency issues, and relevant rules are inherent in each application. They help pull together the concepts and tools presented in this guidebook to a level of direct application. “Follow the money” in this chapter is equivalent to “follow the data.” If the subject does not remember, the data, if processed correctly, will tell the story.