Profiler Overview: Implications for Prevention, Detection, and Investigation
Healthcare waste, fraud, and abuse are pervasive. The only advantage of this fragmented, multilayered industry is that fraudsters have to be very good at lying. Mark Twain could not have said it better: “Always tell the truth. That way, you don’t have to remember what you said.”
This book covers a lot of ground with respect to healthcare episodes and their transactions. Imagine the expertise and training it would require of a fraudster to appreciate the implication of one action throughout the entire P-HCC. Imagine the expertise of appreciating HIPs, ARPs, OFAs, PMAs, service market activities (SMAs), and CMAs behavior. The pipeline tools, combined with the profiler methodology, with EDA integrated into the process to manage high-volume data, are the ultimate tools to ferret out any abnormal behavior.
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