Healthcare fraud : auditing and detection guide /

Healthcare fraud : auditing and detection guide /

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Bibliographic Details
Author / Creator:Busch, Rebecca S.
Imprint:Hoboken, N.J. : John Wiley & Sons, c2008.
Description:xvii, 286 p. : ill. ; 24 cm.
Language:English
Subject:
Medicare fraud.
Medicaid fraud.
Medical care -- Law and legislation -- United States -- Criminal provisions.
Medicaid fraud.
Medical care -- Law and legislation -- Criminal provisions.
Medicare fraud.
United States.
Format: Print Book
URL for this record:http://pi.lib.uchicago.edu/1001/cat/bib/6643892
Hidden Bibliographic Details
Varying Form of Title:Health care fraud
ISBN:9780470127100 (cloth : alk. paper)
0470127104 (cloth : alk. paper)
Notes:Includes index.
Summary:"According to private and public estimates, approximately $24 million is lost per hour to healthcare waste, fraud, and abuse. A must-have reference for auditors, fraud investigators, and healthcare managers, Healthcare Fraud: Auditing and Detection Guide 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"--Provided by publisher.
Table of Contents:
  • Preface
  • Acknowledgments
  • Chapter 1. Introduction to Healthcare Fraud
  • What Is Healthcare Fraud?
  • What Does Healthcare Fraud Look Like?
  • Healthcare Fraud in the United States
  • Healthcare Fraud in International Markets
  • Who Commits Healthcare Fraud?
  • What Is Healthcare Fraud Examination?
  • The Healthcare Continuum: An Overview
  • Healthcare Fraud Overview: Implications for Prevention, Detection, and Investigation
  • Chapter 2. Defining Market Players within the Healthcare Continuum
  • The Patient
  • Who Is the Patient?
  • What Are Some Examples of Patient Fraud?
  • How Does the Patient Role Relate to Other Healthcare Continuum Players?
  • The Provider
  • Who Is the Provider?
  • What Are Some Examples of Provider Fraud?
  • How Does the Provider Role Relate to Other Healthcare Continuum Players?
  • The Payer
  • Who Is the Payer?
  • What Are Some Examples of Payer Fraud?
  • How Does the Payer Role Relate to Other Healthcare Continuum Players?
  • The Employer/Plan Sponsor
  • Who Is the Employer/Plan Sponsor?
  • What Are Some Examples of Employer/Plan Sponsor Fraud?
  • How Does the Employer/Plan Sponsor Role Relate to Other Healthcare Continuum Players?
  • The Vendor and the Supplier
  • Who Are the Vendor and the Supplier?
  • What Are Some Examples of Vendor and Supplier Fraud?
  • How Do the Vendor and Supplier Roles Relate to Other Healthcare Continuum Players?
  • The Government
  • Who Is the Government?
  • What Are Some Examples of Government Fraud?
  • How Does the Government Role Relate to Other Healthcare Continuum Players?
  • Organized Crime
  • Who Is Organized Crime?
  • How Does the Organized Crime Role Relate to Other Healthcare Continuum Players?
  • Market Players Overview: Implications for Prevention, Detection, and Investigation
  • Chapter 3. 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 4. Health Information Pipelines
  • The Auditor's Checklist
  • What Are the Channels of Communication in a Health Information Pipeline?
  • The Patient
  • The Provider
  • The Payer
  • The Employer/Plan Sponsor
  • The Vendor/Supplier
  • The Government Plan Sponsor
  • Unauthorized Parties
  • HIP Overview: Implications for Prevention, Detection, and Investigation
  • Chapter 5. Accounts Receivable Pipelines
  • Overview of Healthcare Reimbursement
  • Types of Reimbursement Models
  • Fee-for-Service Model
  • Prospective Model
  • Capitation-Structured Model
  • Data Contained in Accounts Receivable Pipelines
  • Accounts Receivable Pipelines by HCC Player
  • The Patient
  • The Provider
  • The Payer
  • The Employer/Plan Sponsor
  • Others
  • ARP Overview: Implications for Prevention, Detection, and Investigation
  • Chapter 6. Operational Flow Activity
  • Operational Flow Activity Assessment
  • The Patient
  • The Provider
  • The Payer
  • The Employer
  • The "Other"
  • OFA Overview: Implications for Prevention, Detection, and Investigation
  • Chapter 7. 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 8. Data Management
  • Data Management
  • Market Example: Setting Up a Claims RDBMS
  • Data Management Overview: Implications for Prevention, Detection, and Investigation
  • References
  • Chapter 9. Normal Infrastructure
  • Normal Profile of a Fraudster
  • What Types of People or Entities Commit Fraud?
  • What Is the Key Element of a Fraudster?
  • Anomalies and Abnormal Patterns
  • Normal Infrastructure Overview: Implications for Prevention, Detection, and Investigation
  • Chapter 10. Normal Infrastructure and Anomaly Tracking Systems
  • The Patient
  • Sample Patient Fraud Scenarios
  • Data Management Considerations
  • The Untold Story
  • The Provider
  • Sample Provider Fraud Scenarios
  • Data Management Considerations
  • The Untold Story
  • The Payer
  • Sample Payer Fraud Scenarios
  • Data Management Considerations
  • The Untold Story
  • The Vendor/Other Parties
  • Sample Vendor/Other Fraud Scenarios
  • Data Management Considerations
  • The Untold Story
  • Organized Crime
  • Sample Organized Crime Fraud Scenarios
  • Data Management Considerations
  • The Untold Story
  • Normal Infrastructure and Anomaly Tracking Systems Overview: Implications for Prevention, Detection, and Investigation
  • Chapter 11. Components of the Data Mapping Process
  • What Is Data Mapping?
  • Data Mapping Overview: Implications for Prevention, Detection, and Investigation
  • Chapter 12. Components of the Data Mining Process
  • What Is Data Mining?
  • Data Mining in Healthcare
  • Components of the Data Mining Process within the HCC
  • Data Mining Overview: Implications for Prevention, Detection, and Investigation
  • Chapter 13. 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 14. Data Analysis Models
  • Detection Model
  • Pipeline Application
  • Detection Model Application
  • Investigation Model
  • Mitigation Model
  • Prevention Model
  • Response Model
  • Recovery Model
  • Data Analysis Model Overview: Implications for Prevention, Detection, and Investigation
  • Chapter 15. 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 16. 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 17. Market Implications
  • The Myth
  • "Persistent"
  • "Persuasive"
  • "Unrealistic"
  • Market Overview: Implications for Prevention, Detection, and Investigation
  • Chapter 18. Conclusions
  • Micromanagement Perspective
  • Macromanagement Perspective
  • Overview of Prevention, Detection, and Investigation
  • Index
Purchased from the Charles W. Boand Law School Library Fund bookplate

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