Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

The Consequence Healthcare Continuum (C-HCC)

C-HCC Definition

The fourth level of analysis (Exhibit 3.4) is based on the consequence healthcare continuum (C-HCC). C-HCC analysis identifies and measures risk of all associated behaviors and activities to ensure that all required processes are present in the healthcare marketplace. Within each continuum are data pipelines to serve as a guide in obtaining relevant information to secure for your audit or investigation. They are referenced in this chapter and discussed in more detail in subsequent chapters in this book. Examples, including how to use the pipelines, will be provided within each continuum, and the C-HCC will include additional assessments for measurement of damages. The pipeline categories are noted in the context of “operational and financial integrity issues” to be discerned in the evaluation of damages. They are noted and referenced as follows:

• HIP, health information pipeline—identify route and use of health informant
• ARP, accounts receivable pipeline—identify the monetary impact
• OFA, operational flow activity—identify the relevant business function
• PMA, product market activity—identify the relevant product
• SMA, service market activity—identify the relevant service
• CMA, consumer market activity—identify the appropriate type of patient

Exhibit 3.4 Consequence Healthcare Continuum (C-HCC)

Source: Medical Business Associates, Inc. (www.mbaaudit.com)

C-HCC analysis is complicated by the fact that the behaviors and ...