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Healthcare Fraud Auditing and Detection Guide

ISBN-10: 0470127104
ISBN-13: 9780470127100
Edition: 2008
Authors: Rebecca S. Busch
List price: $78.95
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Description: Healthcare Fraud: Auditing and Detection Guide provides comprehensive guidance on auditing and fraud detection for healthcare providers and company healthcare plans.

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Book details

List price: $78.95
Copyright year: 2008
Publisher: John Wiley & Sons, Incorporated
Publication date: 12/4/2007
Binding: Hardcover
Pages: 304
Size: 6.25" wide x 9.25" long x 1.00" tall
Weight: 1.188
Language: English

Healthcare Fraud: Auditing and Detection Guide provides comprehensive guidance on auditing and fraud detection for healthcare providers and company healthcare plans.

Preface
Acknowledgments
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
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
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
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
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
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
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
Data Management
Data Management
Market Example: Setting Up a Claims RDBMS
Data Management Overview: Implications for Prevention, Detection, and Investigation
References
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
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
Components of the Data Mapping Process
What Is Data Mapping?
Data Mapping Overview: Implications for Prevention, Detection, and Investigation
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
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
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
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
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
Market Implications
The Myth
"Persistent"
"Persuasive"
"Unrealistic"
Market Overview: Implications for Prevention, Detection, and Investigation
Conclusions
Micromanagement Perspective
Macromanagement Perspective
Overview of Prevention, Detection, and Investigation
Index

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