Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Unauthorized Parties

This chapter introduces the concept of HIPs. The purpose is to illustrate all the operational functions in which patient health information (PHI) (and business data associated with PHI) can be generated, expanded on, and transferred. When it comes to healthcare fraud, it is important to understand that health information equals money. As a result, significant vulnerabilities exist among all players when it comes to breaches of internal controls. Many fraud schemes are perpetuated by obtaining health information to convert into a financial scheme or initiate identity theft. That theft could result from direct access to specific information or direct access to a product or supply that is associated with a specific patient or operational function.

An unauthorized party is any individual or organized entity that penetrates the operational function of one or more market players in the P-HCC to perpetuate its scheme. With respect to unauthorized parties, the audit methodology checklist applies to the P-HCC chart presented in Exhibit 10.7, which illustrates each of the market players.

Exhibit 10.7 P-HCC Chart

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

Conceptualize the HIPs of the market players discussed in this chapter. They provide greater details of each component represented in the P-HCC noted in Exhibit 10.7. Apply the auditor methodology ...