Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Product, Service, and Consumer Market Activity Overview: Implications for Prevention, Detection, and Investigation

The PMA and SMA, blended with the CMA, contribute to the understanding of both healthcare fraud and economic structural fraud. These market activity issues are applicable throughout the P-HCC. They can be isolated by market player or occur in collusion with one or more continuum players. For example, an accident crime ring can involve the injured patient, the provider treating the patient, and the claims adjustor. The relevant PMA would be manipulation of insurance products. By applying the checklists reviewed in this chapter, internal controls can be initiated to prevent this type of activity.

From a detection and investigation viewpoint, the checklists provided will help present the opportunity to mitigate damage and stop the bleeding, as well as collect sufficient evidence for a successful prosecution. That being said, we are not done. We have had extensive discussion in understanding the environment. The fragmented high volume of healthcare comes with a huge price, and that is lots of data. Effective management of data requires an understanding of how to find it. Once it is found, it has to be mapped and mined correctly. Ultimately, preparation is the key to effective prevention, detection, and investigation of healthcare fraud and economic structural fraud.