Healthcare Fraud

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. Traveler—Recap 77 Continuum Audit Progression—Recap 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. Traveler—Recap 85 Continuum Audit Progression—Recap 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. Traveler—Recap 93 Continuum Audit Progression—Recap 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. Traveler—Recap 98 The Rules Based Healthcare Continuum (R-HCC) 99 Continuum Audit Progression—Summary 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 Auditor’s 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