Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Recovery and Profilers

Recovery profilers are the descriptions of behavioral characteristics and traits of data elements, representing all the parties that have been noted during a series of referential comparisons. Referential analysis is the comparison of a data element to a specified context. In the recovery model, the specified context is what monies are left or available to compensate for the fraud and the damages that resulted from the perpetrator’s activities. An analysis is required of the possible sources.

The first step is to obtain a comprehensive asset profile of all parties identified. For the provider, the likelihood of utilizing any physical supplies that are found and recovered would represent a high risk, since it is not known how they were stored. If an employee was involved in the theft, the provider may actually recover from its crime policy. The most likely source would be through the distribution of assets seized by the perpetrators. The unfortunate reality of fraud, though, is that once the asset is stolen, it is gone. A high expectation for recovery is not very promising. Damage control often involves preventing the activity from happening again. Having the perpetrators prosecuted and wearing the color orange for a long time will help prevent other victims.

Exhibit 22.13 represents how this topic would be approached utilizing the recovery profiler.

Exhibit 22.13 Recovery Profiler

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