Healthcare Fraud: Auditing and Detection Guide

Praise for the previous edition of Healthcare Fraud Auditing and Detection Guide

"Rebecca Busch has taken the cumbersome and complex subject of healthcare fraud and dissected it into well–defined parts. Her thoughtful discussion of how and where these parts provide opportunities for fraud and how to detect and prevent it is the essence of this work. This book is a must–read for anyone involved in the prevention, detection, and investigation of healthcare fraud."
Robert M. Bryant President and Chief Executive Officer, National Insurance Crime Bureau

"Fraud continues to be a major subject area for internal auditors. Recent studies by the IIA show that healthcare audits are in the top ten subject areas audited. This book speaks to the necessary background that internal auditors should have when auditing healthcare activities so that they can have the necessary skills to look for and deal with potential fraudulent situations. I recommend this book be part of every internal audit department′s library."
Dave Richards, CIA, CPAPresident, The Institute of Internal Auditors

"The cost of healthcare fraud continues to escalate each year. It is a terrible burden on our already fragile healthcare system. This book will provide anti–fraud professionals with a valuable resource to help combat this critical problem."
James D. Ratley, CFEPresident, Association of Certified Fraud Examiners

"Rebecca Busch′s Healthcare Fraud: Auditing and Detection Guide fills a critical gap in anti–fraud literature. Written professionally and precisely, yet eminently readable, this book will be the ′go to′ source for managers, academics, attorneys, auditors, and fraud examiners involved in healthcare. Healthcare Fraud: Auditing and Detection Guide demonstrates Ms. Busch′s expertise and depth of knowledge in the area of healthcare fraud, and is testimony as to why she is such a sought–after speaker and educator."
William J. Kresse, MS, JD, CPA, CFEAssistant Professor, Saint Xavier UniversityGraham School of Management2007 ACFE Educator of the Year

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

What Is Data Mining? 215

Data Mining Overview: Implications for Prevention, Detection, and Investigation 219

CHAPTER 19 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

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.