Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

The Rules Based Healthcare Continuum (R-HCC)

R-HCC Definition

The sixth and final continuum incorporates an understanding of “rules” by continuum that each market player is subject to. The rules based healthcare continuum is illustrated in Exhibit 3.6. This is further layered by the subject matter of each pipeline (HIP, ARP, OFA, PMA, SMA, and CMA) within each segment. The process, in essence, is structured to avoid missing information, identify gaps, and generate incontrovertible facts. The rules, in essence, govern the monetary and business drivers that may or may not be contractually driven. It is important to distinguish rules. Examples of types of rules for consideration include:

• General principals and market standards
• Governmental agencies and regulations governing conduct
• Agency code of regulation
• Entities’ plan documents of a program
• Legal statutes, case law, and legislation

Exhibit 3.6 Rules Based Healthcare Continuum (R-HCC)

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

The concepts of the continuum audit and investigative model have been applied in nontraditional industry segments like mortgage and transportation. In essence, the continuum audit and investigative model focuses on the following layers:

• The players (P-HCC)
• Benchmark data (S-HCC)
• Information systems—location, format, housing of data (I-HCC)
• Risk—identification of road blocks (T-HCC)