Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Service Market Activity

SMA is identifying the professional and nonprofessional support services provided to patients and their families. Another perspective in the analytics of a healthcare service is lining up the products that are charged to a patient with the professionals who are providing those services. Does the skill set match? The expectation would be that if the facility is purchasing cancer drugs, the professional staff should include physicians who are trained in oncology. The facility should be structured to treat these patients while receiving the cancer medication. In continuing this example, we progress by adding the SMA component to the audit process (see Exhibit 13.2). In the data set provided for this example, a red flag would occur prior to the next step. We have Dr. Rheumatoid receiving 340 B cancer drugs. He does not have the patient population or the staff to support the provision of the drugs. This would then lead us to take a closer look at the patients in receipt of the medications. This would require a CMA analysis.

Exhibit 13.2 Product Market and Service Market Activity

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