Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Financial Errors and Profilers

Finance involves several components. The first is the world of managing revenues. It includes anything that will impact the amount of money paid, how it is processed, and the parties involved with the transaction. Finance affects all legitimate and illegitimate P-HCC players. Second, finance involves resources such as research grants, capital loans and expenditures, resource expenditures, credit lines, reserve allocations, and cost reports. In healthcare, financial cost reports can help a hospital receive a disproportionate share reimbursement from Medicare. Finally, finance is also the science of managing money.

This science requires the understanding of errors. Simply put, an error is a deviation from the correct path of a transaction. When it is referred to as an error, it is a mistake. This concept is consistent with a previous discussion in understanding what is normal within a set of financial transactions. Anything else is abnormal and should be evaluated for audit, with a potential progression for investigation. Financial profilers target the descriptive behavioral characteristics of money matters. The traits of the data elements are noted when transactions, in particular, contractual terms and monetary amounts, are processed through exploratory data analysis (EDA) referential activity. Money matters typically include clinical content or operational issues during the referential analysis.

Recall the case of Pain Reliever RN in Chapter 21. ...