Preface xiii
Acknowledgments xvii
Chapter 1 Introduction to Healthcare Fraud 1
What Is Healthcare Fraud? 2
Healthcare Fraud in the United States 4
Healthcare Fraud in International Markets 4
What Does Healthcare Fraud Look Like? 5
Who Commits Healthcare Fraud? 9
What Is Healthcare Fraud Examination? 11
The Primary Healthcare Continuum: An Overview 13
Healthcare Fraud Overview: Implications for Prevention, Detection, and Investigation 14
Notes 17
Chapter 2 Defining Market Players within the Primary Healthcare Continuum 19
The Patient 19
The Provider 24
The Payer 42
The Employer/Plan Sponsor 48
The Vendor and the Supplier 49
The Government 50
Organized Crime 51
Market Players Overview: Implications for Prevention, Detection, and Investigation 53
Chapter 3 Continuum Audit and Investigative Model 57
Market Understanding 58
The Primary Healthcare Continuum (P-HCC) 58
The Secondary Healthcare Continuum (S-HCC) 58
The Information Healthcare Continuum (I-HCC) 62
The Consequence Healthcare Continuum (C-HCC) 63
The Transparency Healthcare Continuum (T-HCC) 65
The Rules Based Healthcare Continuum (R-HCC) 66
Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation 68
Notes 68
Chapter 4 Secondary Healthcare Continuum 69
The Secondary Healthcare Continuum (S-HCC) 71
Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation 75
Notes 75
Chapter 5 Information Healthcare Continuum 77
Case Study Dr. TravelerRecap 77
Continuum Audit ProgressionRecap 78
The Information Healthcare Continuum (I-HCC) 78
Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation 83
Notes 84
Chapter 6 Consequence Healthcare Continuum 85
Case Study Dr. TravelerRecap 85
Continuum Audit ProgressionRecap 86
The Consequence Healthcare Continuum (C-HCC) 86
Economic Business Impact 88
Serviceability and Service Integrity 89
Service, Medical, and Financial Errors 90
Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation 90
Chapter 7 Transparency Healthcare Continuum 93
Case Study Dr. TravelerRecap 93
Continuum Audit ProgressionRecap 94
The Transparency Healthcare Continuum (T-HCC) 95
Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation 96
Chapter 8 Rules Based Healthcare Continuum 97
Case Study Dr. TravelerRecap 98
The Rules Based Healthcare Continuum (R-HCC) 99
Continuum Audit ProgressionSummary 104
Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation 106
Notes 107
Chapter 9 Protected Health Information 109
Health Insurance Portability and Accountability Act of 1996 109
Audit Guidelines in Using Protected Health Information 110
Protected Health Information Overview: Implications for Prevention, Detection, and Investigation 113
Chapter 10 Health Information Pipelines 115
The Auditors Checklist 115
What Are the Channels of Communication in a Health Information Pipeline? 116
Unauthorized Parties 125
Health Information Pipelines Overview: Implications for Prevention, Detection, and Investigation 126
Chapter 11 Accounts Receivable Pipelines 129
Overview of Healthcare Reimbursement 130
Types of Reimbursement Models 131
Data Contained in Accounts Receivable Pipelines 135
Accounts Receivable Pipelines by Healthcare Continuum Player 135
Accounts Receivable Pipelines Overview: Implications for Prevention, Detection, and Investigation 154
Chapter 12 Operational Flow Activity 157
Operational Flow Activity Assessment 157
Operational Flow Activity Overview: Implications for Prevention, Detection, and Investigation 163
Chapter 13 Product, Service, and Consumer Market Activity 165
Product Market Activity 165
Service Market Activity 167
Consumer Market Activity 167
Product, Service, and Consumer Market Activity Overview: Implications for Prevention, Detection, and Investigation 175
Chapter 14 Data Management 177
Data Management 177
Market Example: Setting Up a Claims Relational Database Management System 181
Data Management Overview: Implications for Prevention, Detection, and Investigation 182
References 182
Chapter 15 Normal Infrastructure 185
Normal Profile of a Fraudster 185
Anomalies and Abnormal Patterns 188
Continuum Audit and Investigative Model 188
Normal Infrastructure Overview: Implications for Prevention, Detection, and Investigation 189
Chapter 16 Normal Infrastructure and Anomaly Tracking Systems 191
The Patient 191
The Provider 194
The Payer 198
The Vendor/Other Parties 201
Organized Crime 205
Normal Infrastructure and Anomaly Tracking Systems Overview: Implications for Prevention, Detection, and Investigation 207
Notes 207
Chapter 17 Components of the Data Mapping Process 209
What Is Data Mapping? 209
Data Mapping Overview: Implications for Prevention, Detection, and Investigation 213
Chapter 18 Components of the Data Mining Process 215
Chapter 19 What Is Data Mining? 215
Data Mining Overview: Implications for Prevention, Detection, and Investigation 219
Components of the Data Mapping and Data Mining Process 221
Forensic Application of Data Mapping and Data Mining 224
Data Mapping and Data Mining Overview: Implications for Prevention, Detection, and Investigation 226
Chapter 20 Data Analysis Models 227
Detection Model 227
Investigation Model 230
Mitigation Model 233
Prevention Model 235
Response Model 240
Recovery Model 244
Data Analysis Model Overview: Implications for Prevention, Detection, and Investigation 253
Chapter 21 Clinical Content Data Analysis 255
What Is SOAP? 256
The SOAP Methodology 257
Electronic Records 270
Analysis Considerations with Electronic Records 273
Narrative Discourse Analysis 277
Clinical Content Analysis Overview: Implications for Prevention, Detection, and Investigation 284
Chapter 22 Profilers 287
Fraud and Profilers 287
Medical Errors and Profilers 291
Financial Errors and Profilers 296
Internal Audit and Profilers 300
Recovery and Profilers 302
Anomaly and Profilers 303
Fraud Awareness and Profilers 304
Profiler Overview: Implications for Prevention, Detection, and Investigation 305
Chapter 23 Market Implications 307
The Myth 307
Persistent 310
Persuasive 310
Unrealistic 312
Market Overview: Implications for Prevention, Detection, and Investigation 313
Chapter 24 Conclusions 315
Micromanagement Perspective 315
Macromanagement Perspective 326
Overview of Prevention, Detection, and Investigation 327
About the Author 333
Index 335
