Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Normal Infrastructure Overview: Implications for Prevention, Detection, and Investigation

The first critical component is the understanding of normal infrastructure. The market is too fragmented, layered, and operationally, contractually, and legally segmented to keep track of everything that can break down or to test each vulnerability. That is physically impossible. Therefore, the focus on understanding and monitoring data for anomalies is a key aspect from an operational perspective.

The second critical component is to understand what normal behavior is from a “people perspective.” It is the “people” aspect that contributes to or initiates fraud. According to the ACFE research, similar attributes exist in individuals who cross the line. An employee profile may include an individual who is first to arrive at work, the last to leave, and viewed as a dedicated trooper who never takes vacation time. The red flags are raised when an individual combines a protective behavior toward his or her work and a refusal to take absences from work. The concern by the perpetrator is that if he or she goes on vacation and someone else fills in, whatever activity the perpetrator is involved with may be found out during the absence.

In identifying what is normal in any particular process, it is easy to focus only on what information was said. In gathering descriptions of certain procedures or explanations of various transactions, detection of abnormal activities will materialize. However, the next ...