Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

The Vendor/Other Parties

This group is the largest number of market players and most diverse. It can include any other P-HCC player that is not a plan sponsor, payer, provider, or beneficiary/recipient. This group can range from billing services to ambulance services, durable medical equipment, case management support, and pharmaceuticals. The types of fraud range from healthcare false claim scenarios to economic structural frauds involving complex manipulations of fee schedules and/or contractual misrepresentations.

With respect to market standards on the management of PHI, this group also varies significantly. Groups such as support providers may not be on par with emerging industry standards in established or targeted markets. Also, ancillary players, such as equipment companies, may not be as formal as they should be. The market standards and compliance programs will continue to increase mandates of accountability and for internal controls to protect PHI. On the financial piece, they also tend to be insulated by other market players, on both contractual and operational bases. For example, a patient in the hospital may receive dialysis services; however, those treating the patient are not employees of the hospital but a contracted service. This is a seamless, unknown operational activity. On the financial side, this service can be billed by the contracting party or integrated into the patient’s hospital bill. The contracted vendor often has their own set of records that they ...