Healthcare Fraud

Auditing and Detection Guide

Inbunden, Engelska, 2012

659 kr

Beställningsvara. Skickas inom 10-15 vardagar

Fri frakt för medlemmar vid köp för minst 249 kr.

An invaluable tool equipping healthcare professionals, auditors, and investigators to detect every kind of healthcare fraud According to private and public estimates, billions of dollars are lost per hour to healthcare waste, fraud, and abuse. A must-have reference for auditors, fraud investigators, and healthcare managers, Healthcare Fraud, Second Edition provides tips and techniques to help you spot—and prevent—the "red flags" of fraudulent activity within your organization. Eminently readable, it is your "go-to" resource, equipping you with the necessary skills to look for and deal with potential fraudulent situations. Includes new chapters on primary healthcare, secondary healthcare, information/data management and privacy, damages/risk management, and transparencyOffers comprehensive guidance on auditing and fraud detection for healthcare providers and company healthcare plansExamines the necessary background that internal auditors should have when auditing healthcare activitiesManaging the risks in healthcare fraud requires an understanding of how the healthcare system works and where the key risk areas are. With health records now all being converted to electronic form, the key risk areas and audit process are changing. Read Healthcare Fraud, Second Edition and get the valuable guidance you need to help combat this critical problem.

Produktinformation

Utgivningsdatum2012-05-15
Mått165 x 236 x 31 mm
Vikt579 g
FormatInbunden
SpråkEngelska
Antal sidor368
Upplaga2
FörlagJohn Wiley & Sons Inc
ISBN9781118179802

Tillhör följande kategorier

Hälso- och sjukvård inom Medicin
Brottsutredning och kriminalteknik inom Samhalle och politik
Straffrätt: lagar inom Juridik
Redovisning inom Ekonomi och ledarskap

REBECCA SALTIEL BUSCH, RN, MBA, CCM, CFE, CHS-III, CPC, FHFMA, FIALCP, has a passion to create educated, conscientious healthcare consumers. Recent leadership and professional recognitions include the 2011 Chicago United's Business Leaders of Color Award, 2010 Finalist for the Enterprising Women of the Year Award, and 2009 Recipient of the Influential Women in Business Award by the Business Ledger in partnership with NAWBO. Her entrepreneurial, professional, driven career has resulted in various proprietary audit platforms in multi-market verticals in healthcare, and authorship of over 200 articles, books, and presentations to consumers, government, corporate, and professional entities. Recognized as an expert in her field, she has provided public and forensic expert testimony and participated in public policy discussions and the development of best practice standards. Rebecca currently has seven U.S. design patents and one U.S patent focused on efficacy, risk, FWB, and revenue management within healthcare.

Preface xiiiAcknowledgments xviiChapter 1 Introduction to Healthcare Fraud 1What Is Healthcare Fraud? 2Healthcare Fraud in the United States 4Healthcare Fraud in International Markets 4What Does Healthcare Fraud Look Like? 5Who Commits Healthcare Fraud? 9What Is Healthcare Fraud Examination? 11The Primary Healthcare Continuum: An Overview 13Healthcare Fraud Overview: Implications for Prevention, Detection, and Investigation 14Notes 17Chapter 2 Defining Market Players within the Primary Healthcare Continuum 19The Patient 19The Provider 24The Payer 42The Employer/Plan Sponsor 48The Vendor and the Supplier 49The Government 50Organized Crime 51Market Players Overview: Implications for Prevention, Detection, and Investigation 53Chapter 3 Continuum Audit and Investigative Model 57Market Understanding 58The Primary Healthcare Continuum (P-HCC) 58The Secondary Healthcare Continuum (S-HCC) 58The Information Healthcare Continuum (I-HCC) 62The Consequence Healthcare Continuum (C-HCC) 63The Transparency Healthcare Continuum (T-HCC) 65The Rules Based Healthcare Continuum (R-HCC) 66Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation 68Notes 68Chapter 4 Secondary Healthcare Continuum 69The Secondary Healthcare Continuum (S-HCC) 71Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation 75Notes 75Chapter 5 Information Healthcare Continuum 77Case Study Dr. Traveler—Recap 77Continuum Audit Progression—Recap 78The Information Healthcare Continuum (I-HCC) 78Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation 83Notes 84Chapter 6 Consequence Healthcare Continuum 85Case Study Dr. Traveler—Recap 85Continuum Audit Progression—Recap 86The Consequence Healthcare Continuum (C-HCC) 86Economic Business Impact 88Serviceability and Service Integrity 89Service, Medical, and Financial Errors 90Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation 90Chapter 7 Transparency Healthcare Continuum 93Case Study Dr. Traveler—Recap 93Continuum Audit Progression—Recap 94The Transparency Healthcare Continuum (T-HCC) 95Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation 96Chapter 8 Rules Based Healthcare Continuum 97Case Study Dr. Traveler—Recap 98The Rules Based Healthcare Continuum (R-HCC) 99Continuum Audit Progression—Summary 104Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation 106Notes 107Chapter 9 Protected Health Information 109Health Insurance Portability and Accountability Act of 1996 109Audit Guidelines in Using Protected Health Information 110Protected Health Information Overview: Implications for Prevention, Detection, and Investigation 113Chapter 10 Health Information Pipelines 115The Auditor’s Checklist 115What Are the Channels of Communication in a Health Information Pipeline? 116Unauthorized Parties 125Health Information Pipelines Overview: Implications for Prevention, Detection, and Investigation 126Chapter 11 Accounts Receivable Pipelines 129Overview of Healthcare Reimbursement 130Types of Reimbursement Models 131Data Contained in Accounts Receivable Pipelines 135Accounts Receivable Pipelines by Healthcare Continuum Player 135Accounts Receivable Pipelines Overview: Implications for Prevention, Detection, and Investigation 154Chapter 12 Operational Flow Activity 157Operational Flow Activity Assessment 157Operational Flow Activity Overview: Implications for Prevention, Detection, and Investigation 163Chapter 13 Product, Service, and Consumer Market Activity 165Product Market Activity 165Service Market Activity 167Consumer Market Activity 167Product, Service, and Consumer Market Activity Overview: Implications for Prevention, Detection, and Investigation 175Chapter 14 Data Management 177Data Management 177Market Example: Setting Up a Claims Relational Database Management System 181Data Management Overview: Implications for Prevention, Detection, and Investigation 182References 182Chapter 15 Normal Infrastructure 185Normal Profile of a Fraudster 185Anomalies and Abnormal Patterns 188Continuum Audit and Investigative Model 188Normal Infrastructure Overview: Implications for Prevention, Detection, and Investigation 189Chapter 16 Normal Infrastructure and Anomaly Tracking Systems 191The Patient 191The Provider 194The Payer 198The Vendor/Other Parties 201Organized Crime 205Normal Infrastructure and Anomaly Tracking Systems Overview: Implications for Prevention, Detection, and Investigation 207Notes 207Chapter 17 Components of the Data Mapping Process 209What Is Data Mapping? 209Data Mapping Overview: Implications for Prevention, Detection, and Investigation 213Chapter 18 Components of the Data Mining Process 215Chapter 19 What Is Data Mining? 215Data Mining Overview: Implications for Prevention, Detection, and Investigation 219Components of the Data Mapping and Data Mining Process 221Forensic Application of Data Mapping and Data Mining 224Data Mapping and Data Mining Overview: Implications for Prevention, Detection, and Investigation 226Chapter 20 Data Analysis Models 227Detection Model 227Investigation Model 230Mitigation Model 233Prevention Model 235Response Model 240Recovery Model 244Data Analysis Model Overview: Implications for Prevention, Detection, and Investigation 253Chapter 21 Clinical Content Data Analysis 255What Is SOAP? 256The SOAP Methodology 257Electronic Records 270Analysis Considerations with Electronic Records 273Narrative Discourse Analysis 277Clinical Content Analysis Overview: Implications for Prevention, Detection, and Investigation 284Chapter 22 Profilers 287Fraud and Profilers 287Medical Errors and Profilers 291Financial Errors and Profilers 296Internal Audit and Profilers 300Recovery and Profilers 302Anomaly and Profilers 303Fraud Awareness and Profilers 304Profiler Overview: Implications for Prevention, Detection, and Investigation 305Chapter 23 Market Implications 307The Myth 307“Persistent” 310“Persuasive” 310“Unrealistic” 312Market Overview: Implications for Prevention, Detection, and Investigation 313Chapter 24 Conclusions 315Micromanagement Perspective 315Macromanagement Perspective 326Overview of Prevention, Detection, and Investigation 327About the Author 333Index 335