Healthcare fraud: auditing and detection guide

An invaluable tool equipping healthcare professionals, auditors, and investigators to detect every kind of healthcare fraudAccording 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 tohelp 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 healthcareproviders 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 needto help combat this critical problem. INDICE: PrefaceAcknowledgementsChapter 1 Introduction to Healthcare FraudWhat Is Healthcare Fraud?Healthcare Fraud in the United StatesHealthcare Fraud in International MarketsWhat Does Healthcare Fraud Look Like?Who Commits Healthcare Fraud?What Is Healthcare Fraud Examination?The Primary Healthcare Continuum: An OverviewHealthcare Fraud Overview: Implications for Prevention, Detection, and InvestigationNotesChapter 2 Defining Market Players Within The Primary Healthcare ContinuumThe PatientThe ProviderThe PayerThe Employer/Plan SponsorThe Vendor and the SupplierThe GovernmentOrganized CrimeMarket Players Overview: Implications for Prevention, Detection, and InvestigationChapter 3 Continuum Audit & Investigative ModelMarket UnderstandingThe 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 InvestigationNotesChapter 4 Secondary healthcare continuumThe Secondary healthcare continuum (s-HCC)Audit Contimuum Models Overview: Implications for Prevention, Detection, and InvestigationNotesChapter 5 Information Healthcare ContinuumCase Study Dr. Traveler- RecapContinuum Audit Progression - RecapThe Information Healthcare Continuum (I-HCC)Audit Continuum Models Overview: Implications for Prevention, Detection, and InvestigationNotesChapter 6 Consequence Healthcare ContinuumCase Study Dr. Traveler- RecapContinuum Audit Progression - RecapThe Consequence Healthcare Continuum (c-HCC)Economic Business ImpactServiceability & Service IntegrityService, Medical & Financial ErrorsAudit Continuum Models Overview: Implications for Prevention, Detection, and InvestigationChapter 7 Transparency Healthcare ContinuumCase Study Dr. Traveler - RecapContinuum Audit Progression - RecapThe Transparency Healthcare Continuum (T-HCC)Audit Continuum Models Overview: Implications for Prevention, Detection, and InvestigationChapter 8 Rules Based Healthcare ContinuumCase Study Dr. Traveler- RecapThe Rules Based Healthcare Continuum (R-HCC)Continuum Audit Progression - SummaryAudit Continuum Models Overview: Implications for Prevention, Detection, and InvestigationNotesChapter 9 Protected Health InformationHealth Insurance Portability and Accountability Act of 1996Audit Guidelines in Using PHIProtected Health Information Overview: Implications for Prevention, Detection, and InvestigationChapter 10 Health Information PipelinesThe Auditor's ChecklistWhat Are the Channels of Communication in a Health Information Pipeline?Unauthorized PartiesHIP Overview: Implications for Prevention, Detection, and InvestigationChapter 11 Accounts Receivable PipelinesOverview of Healthcare ReimbursementTypes of Reimbursement ModelsData Contained in Accounts Receivable PipelinesAccounts Receivable Pipelines by HCC PlayerARP Overview: Implications for Prevention, Detection, and InvestigationChapter 12 Operational Flow ActivityOperational Flow Activity AssessmentOFA Overview: Implications for Prevention, Detection, and InvestigationChapter 13 Product, Service, and Consumer Market ActivityProduct Market ActivityService Market ActivityConsumer Market ActivityPMA, SMA, and CMA Overview: Implications for Prevention, Detection, and InvestigationChapter 14 Data ManagementData ManagementMarket Example: Setting Up a Claims RDBMSData Management Overview: Implications for Prevention, Detection, and InvestigationREFERENCESChapter 15 Normal InfrastructureNormal Profile of a FraudsterAnomalies and Abnormal PatternsContinuum Audit & Investigative ModelNormal Infrastructure Overview: Implications for Prevention, Detection, and InvestigationChapter 16 Normal Infrastructure and Anomaly Tracking SystemsThe PatientThe PayerThe Vendor/Other PartiesOrganized CrimeNormal Infrastructure andAnomaly Tracking Systems Overview: Implications for Prevention, Detection, and InvestigationNotesChapter 17 Components of the Data Mapping ProcessWhat Is Data Mapping?Data Mapping Overview: Implications for Prevention, Detection, andInvestigationChapter 18 Components of the Data Mining ProcessWhat Is Data Mining?Data Mining Overview: Implications for Prevention, Detection, and InvestigationChapter 19 Components of the Data Mapping and Data Mining ProcessForensicApplication of Data Mapping and Data MiningData Mapping and Data Mining Overview: Implications for Prevention, Detection, and InvestigationChapter 20 Data Analysis ModelsDetection ModelInvestigation ModelMitigation ModelPrevention ModelResponse ModelRecovery ModelData Analysis Model Overview: Implications for Prevention, Detection, and InvestigationChapter 21 Clinical Content Data AnalysisWhat Is SOAP?The SOAP MethodologyElectronic RecordsAnalysis Considerations with Electronic RecordsNarrative Discourse AnalysisClinical Content Analysis Overview: Implications for Prevention, Detection, and InvestigationChapter 22 ProfilersFraud and ProfilersMedical Errors and ProfilersFinancial Errors and ProfilersInternal Audit and ProfilersRecovery and ProfilersAnomaly and ProfilersFraud Awareness and ProfilersProfiler Overview: Implications for Prevention, Detection, and InvestigationChapter 23 Market ImplicationsThe Myth“Persistent”“Persuasive”“Unrealistic”Market Overview: Implications for Prevention, Detection, and InvestigationChapter 24 ConclusionsMicromanagement PerspectiveMacromanagement PerspectiveOverview of Prevention, Detection, and InvestigationAbout the AuthorIndex

• ISBN: 978-1-118-17980-2
• Editorial: John Wiley & Sons
• Encuadernacion: Cartoné
• Páginas: 368
• Fecha Publicación: 18/05/2012
• Nº Volúmenes: 1
• Idioma: Inglés