Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Protected Health Information Overview: Implications for Prevention, Detection, and Investigation

The use of PHI is the cornerstone to committing fraud in healthcare. With respect to fraud, view PHI as equivalent to money. Inappropriate access to PHI at the registration function in a business can allow the perpetrator to use an existing patient to generate a false claim. Information like a diagnosis or procedure can be valuable in generating a false claim or stealing an insurance check once the claim is paid. A perpetrator can just steal the patient’s demographic information to obtain false credit. To perpetuate most healthcare fraud schemes, we need to have a patient—or at least the PHI associated with that patient. Fraud requires information on diagnoses and procedures so they can be mimicked in a false environment. It may be noted that the patient is alive, dead, not alert, or alert and oriented to person, place, and time. Schemes have been perpetuated in all patienttype scenarios.

The audit guidelines set forth in this chapter identify the process of operational flowcharts. Later in this book, we look at the skill of operational flows that define normal business function. Normal is introduced in the context of understanding anomalies. Anomaly detection is critical in the healthcare fraud environment, in particular because the prevalence and evolution of schemes are occurring at an accelerated rate. Fraud is an industry in and of itself. Each new type of possible scheme leaves ...