Healthcare Fraud Auditing and Detection Guide

ISBN-10: 1118179803
ISBN-13: 9781118179802
Edition: 2nd 2012
Authors: Rebecca S. Busch
List price: $90.00 Buy it from $50.45
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Description: This second edition provides comprehensive guidance on auditing and fraud detection for healthcare providers and company healthcare plans.  New chapters have been added covering a comprehensive auditing model developed by the author on all of the  More...

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Book details

List price: $90.00
Edition: 2nd
Copyright year: 2012
Publisher: John Wiley & Sons Canada, Limited
Publication date: 5/1/2012
Binding: Hardcover
Pages: 340
Size: 6.25" wide x 9.25" long x 1.25" tall
Weight: 1.518
Language: English

This second edition provides comprehensive guidance on auditing and fraud detection for healthcare providers and company healthcare plans.  New chapters have been added covering a comprehensive auditing model developed by the author on all of the key elements that must be addressed: Primary Healthcare, Secondary Healthcare, Information/Data Management and Privacy, Damages/Risk Management, and transparency.  In addition to six new chapters, the current edition material will all be updated and brought up to date.

Preface
Acknowledgments
Introduction to Healthcare Fraud
What Is Healthcare Fraud?
Healthcare Fraud in the United States
Healthcare Fraud in International Markets
What Does Healthcare Fraud Look Like?
Who Commits Healthcare Fraud Examination?
What Is Healthcare Fraud Examination?
The Primary Healthcare Continuum: An Overview
Healthcare Fraud Overview: Implications for Prevention, Detection, and Investigation
Notes
Defining Market Players within the Primary Healthcare Continuum
The Patient
The Provider
The Prayer
The Employer/Plan Sponsor
The Vendor and the Supplier
The Government
Organized Crime
Market Players Overview: Implications for Prevention, Detection, and Investigation
Continuum Audit and Investigative Model
Market Understanding
The 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 Investigation
Notes
Secondary Healthcare Continuum
The Secondary Healthcare Continuum (S-HCC)
Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation
Notes
Information Healthcare Continuum
Case Study Dr. Traveler-Recap
Continuum Audit Progression-Recap
The Information Healthcare Continuum (I-HCC)
Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation
Notes
Consequence Healthcare Continuum
Case Study Dr. Traveler-Recap
Continuum Audit Progression-Recap
The Consequence Healthcare Continuum (C-HCC)
Economic Business Impact
Serviceability and Service Integrity
Service, Medical, and Financial Errors
Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation
Transparency Healthcare Continuum
Case Study Dr. Traveler-Recap
Continuum Audit Progression-Recap
The Transparency Healthcare Continuum (T-HCC)
Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation
Rules Based Healthcare Continuum
Case Study Dr. Traveler-Recap
The Rules Based Healthcare Continuum (R-HCC)
Continuum Audit Progression-Summary
Audit Continuum Models Overview: Implications for Prevention, Detection, and Investigation
Notes
Protected Health Information
Health Insurance Portability and Accountability Act of 1996
Audit Guidelines in Using Protected Health Information
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?
Unauthorized Parties
Health Information Pipelines Overview: Implications for Prevention, Detection, and Investigation
Accounts Receivable Pipelines
Overview of Healthcare Reimbursement
Types of Reimbursement Models
Data Contained in Accounts Receivable Pipelines
Accounts Receivable Pipelines by Healthcare Continuum Players
Accounts Receivable Pipelines Overview: Implications for Prevention, Detection, and Investigation
Operation Flow Activity
Operational Flow Activity Assessment
Operational Flow Activity Overview: Implications for Prevention, Detection, and Investigation
Product, Service, and Consumer Market Activity
Product Market Activity
Service Market Activity
Consumer Market Activity
Product, Service, and Consumer Market Activity Overview: Implications for Prevention, Detection, and Investigation
Data Management
Data Management
Market Example: Setting Up a Claims Relational Database Management System
Data Management Overview: Implications for Prevention, Detection, and Investigation
References
Normal Infrastructure
Normal Profile of a Fraudster
Anomalies and Abnormal Patterns
Continuum Audit and Investigative Model
Normal Infrastructure Overview: Implications for Prevention, Detection, and Investigation
Normal Infrastructure and Anomaly Tracking Systems
The Patient
The Provider
The Payer
The Vendor/Other Parties
Organized Crime
Normal Infrastructure and Anomaly Tracking Systems Overview: Implications for Prevention, Detection, and Investigation
Notes
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 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
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
About the Author
Index

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