What Is Healthcare Fraud Examination?
Auditing and investigating healthcare fraud is about seeing beyond the eclipse created by defrauders and deciphering who, what, where, when, why, and how. It is about creating an archaeological road map into the discovery of incontrovertible truth. Audit and investigative techniques excavate information that appears to have been extinguished.
To examine means “to observe carefully or critically; inspect” or “to study or analyze” an issue (American Heritage Dictionary, 4th ed.). Fraud examination, then, is the thorough inspection, study, or analysis of an issue relating to fraud. The Association of Certified Fraud Examiners (ACFE) is an organization dedicated to the study of fraud across all industry sectors. It is a global professional association providing antifraud information and education to help members fight fraud effectively. As of this writing, the ACFE has 40,000 members in 125 countries; its 103 local chapters provide education, outreach, and networking opportunities. In its coursework, the ACFE provides the figure describing fraud examination shown in Exhibit 1.2.
One common type of fraud examination is forensic analysis, which reconstructs a past event using the health data transactions made by some or all of the parties shown in ...
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