Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

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

Health information is the data, the meaning, the everyday usage of any element created throughout the P-HCC. It can result from the generation of, processing of, mining of, mapping of, manipulation of, and organization of data in a way that adds diagnostics, knowledge, solutions, and alternatives to the person receiving or sending it. It includes communications, instructions, meanings, patterns, perceptions, and representations of the patient and those involved with and impacted by the patient.

HIPs represent the operational decision trees in which such information is typically channeled. The implications for prevention are primarily focused on internal controls. Do we have the audit log infrastructure and edit controls to flag a transaction before it becomes an issue? If a breach does occur, do we have the controls in place to detect anomalies? Can we trace them to their generation? Can they be traced to the point of processing or to any form of their use? HIPs should serve as a roadmap for detection. Again, if we follow all its possible uses, we should be able to detect the schemes that are perpetuated with health information.

Remember, health information is equivalent to money (i = $). During the generation of, transfer, and use of health information in the normal course of business, be sure to keep a watchful eye for how it can be converted toward an illicit monetary gain. A simple ...