Preface
Acknowledgements
Chapter 1 Introduction to Healthcare Fraud
What Is Healthcare Fraud?
Healthcare Fraud in the United States
Healthcare Fraud in International Markets
What Does Healthcare Fraud Look Like?
Who Commits Healthcare Fraud?
What Is Healthcare Fraud Examination?
The Primary Healthcare Continuum: An Overview
Healthcare Fraud Overview: Implications for Prevention, Detection, and Investigation
Notes
Chapter 2 Defining Market Players Within The Primary Healthcare Continuum
The Patient
The Provider
The Payer
The Employer/Plan Sponsor
The Vendor and the Supplier
The Government
Organized Crime
Market Players Overview: Implications for Prevention, Detection, and Investigation
Chapter 3 Continuum Audit & Investigative Model
Market Understanding
The Primary healthcare continuum (P-HCC)
The Secondary healthcare continuum (s-HCC)
The Information healthcare continuum (I-HCC)
The consequence healthcare continuum (c-HCC)
The transparency healthcare continuum (t-HCC)
The rules based healthcare continuum (r-HCC)
Audit continuum models Overview: Implications for Prevention, Detection, and Investigation
Notes
Chapter 4 Secondary healthcare continuum
The Secondary healthcare continuum (s-HCC)
Audit Contimuum Models Overview: Implications for Prevention, Detection, and Investigation
Notes
Chapter 5 Information Healthcare Continuum
Case Study Dr. Traveler– Recap
Continuum Audit Progression - Recap
The Information Healthcare Continuum (I-HCC)
Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation
Notes
Chapter 6 Consequence Healthcare Continuum
Case Study Dr. Traveler– Recap
Continuum Audit Progression - Recap
The Consequence Healthcare Continuum (c-HCC)
Economic Business Impact
Serviceability & Service Integrity
Service, Medical & Financial Errors
Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation
Chapter 7 Transparency Healthcare Continuum
Case Study Dr. Traveler – Recap
Continuum Audit Progression – Recap
The Transparency Healthcare Continuum (T-HCC)
Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation
Chapter 8 Rules Based Healthcare Continuum
Case Study Dr. Traveler – Recap
The Rules Based Healthcare Continuum (R-HCC)
Continuum Audit Progression - Summary
Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation
Notes
Chapter 9 Protected Health Information
Health Insurance Portability and Accountability Act of 1996
Audit Guidelines in Using PHI
Protected Health Information Overview: Implications for Prevention, Detection, and Investigation
Chapter 10 Health Information Pipelines
The Auditor's Checklist
What Are the Channels of Communication in a Health Information Pipeline?
Unauthorized Parties
HIP Overview: Implications for Prevention, Detection, and Investigation
Chapter 11 Accounts Receivable Pipelines
Overview of Healthcare Reimbursement
Types of Reimbursement Models
Data Contained in Accounts Receivable Pipelines
Accounts Receivable Pipelines by HCC Player
ARP Overview: Implications for Prevention, Detection, and Investigation
Chapter 12 Operational Flow Activity
Operational Flow Activity Assessment
OFA Overview: Implications for Prevention, Detection, and Investigation
Chapter 13 Product, Service, and Consumer Market Activity
Product Market Activity
Service Market Activity
Consumer Market Activity
PMA, SMA, and CMA Overview: Implications for Prevention, Detection, and Investigation
Chapter 14 Data Management
Data Management
Market Example: Setting Up a Claims RDBMS
Data Management Overview: Implications for Prevention, Detection, and Investigation
REFERENCES
Chapter 15 Normal Infrastructure
Normal Profile of a Fraudster
Anomalies and Abnormal Patterns
Continuum Audit & Investigative Model
Normal Infrastructure Overview: Implications for Prevention, Detection, and Investigation
Chapter 16 Normal Infrastructure and Anomaly Tracking Systems
The Patient
The Payer
The Vendor/Other Parties
Organized Crime
Normal Infrastructure and Anomaly Tracking Systems Overview: Implications for Prevention, Detection, and Investigation
Notes
Chapter 17 Components of the Data Mapping Process
What Is Data Mapping?
Data Mapping Overview: Implications for Prevention, Detection, and Investigation
Chapter 18 Components of the Data Mining Process
What Is Data Mining?
Data Mining Overview: Implications for Prevention, Detection, and Investigation
Chapter 19 Components of the Data Mapping and Data Mining Process
Forensic Application of Data Mapping and Data Mining
Data Mapping and Data Mining Overview: Implications for Prevention, Detection, and Investigation
Chapter 20 Data Analysis Models
Detection Model
Investigation Model
Mitigation Model
Prevention Model
Response Model
Recovery Model
Data Analysis Model Overview: Implications for Prevention, Detection, and Investigation
Chapter 21 Clinical Content Data Analysis
What Is SOAP?
The SOAP Methodology
Electronic Records
Analysis Considerations with Electronic Records
Narrative Discourse Analysis
Clinical Content Analysis Overview: Implications for Prevention, Detection, and Investigation
Chapter 22 Profilers
Fraud and Profilers
Medical Errors and Profilers
Financial Errors and Profilers
Internal Audit and Profilers
Recovery and Profilers
Anomaly and Profilers
Fraud Awareness and Profilers
Profiler Overview: Implications for Prevention, Detection, and Investigation
Chapter 23 Market Implications
The Myth
“Persistent”
“Persuasive”
“Unrealistic”
Market Overview: Implications for Prevention, Detection, and Investigation
Chapter 24 Conclusions
Micromanagement Perspective
Macromanagement Perspective
Overview of Prevention, Detection, and Investigation
About the Author
Index
