Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

What Are the Channels of Communication in a Health Information Pipeline?

The Patient

Exhibit 10.1 represents a sample operational flow from the patient perspective. The auditor’s checklist should be a guide through each activity. The exhibit contains a sample of general activity questions. The auditor should document the communication component of each response. For example, if the patient was referred, was this referral made orally or in writing? Is it documented in a written form, such as a prescription?

Exhibit 10.1 Patient’s HIP

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

Exhibit 10.1 begins with Insurance Plan Status. If the patient has insurance, then you want to collect any information associated with this plan. Ask the patient if he or she had any difficulties with denials for coverage or reimbursement from the insurance company (plan sponsor). During a recent patient interview, when I presented this question, the patient responded: “They really do not pay much.” A few other statements were suspect. A quick Internet search revealed that the Texas-based carrier was being investigated by the attorney general of Massachusetts and the State of Texas for selling fraudulent insurance. This would be a RED flag.

The next step involves the patient pursuing a product or service. Sample follow-up questions may include whether the patient was sent by referral. If ...