Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

The Myth

The term fragmented is used throughout this book in discussions about the primary healthcare continuum (P-HCC), along with the introductions of the secondary, information, consequence, transparency, and rules based healthcare continuums (Model Continuums -HCC). Fragmented in this context describes a disorganized process that exists in or functions through separate parts. The process is not unified. The audit tools described in this book focus on finding all the pieces so that they can be integrated for the most appropriate type of audit or investigation. The integration also allows for effective detection.

Segmented is about taking these individual fragments and dividing them up further. In reimbursement, we divide up constantly by cost shifting the price of healthcare, excluding services and excluding preexisting conditions. In healthcare, we see various HCC players attempting to further segment various parts in the provision of healthcare services. I often hear something like this from consumers: “Our insurance just dropped four major hospitals in our area. My number-one complaint with what’s wrong in healthcare is that I cannot choose where to go or what doctor to see.” Cost shifting can occur by segmenting choices: Patients are directed to lower-cost providers with fewer service offerings; the system controls their choices and access.

What does this look like to a consumer? Take a recent visit to my family dentist. My son had to get a tooth pulled. The dentist informed ...