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| Preface | |
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| Acknowledgments | |
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| Introduction to Healthcare Fraud | |
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| What Is Healthcare Fraud? | |
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| What Does Healthcare Fraud Look Like? | |
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| Healthcare Fraud in the United States | |
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| Healthcare Fraud in International Markets | |
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| Who Commits Healthcare Fraud? | |
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| What Is Healthcare Fraud Examination? | |
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| The Healthcare Continuum: An Overview | |
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| Healthcare Fraud Overview: Implications for Prevention, Detection, and Investigation | |
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| Defining Market Players within the Healthcare Continuum | |
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| The Patient | |
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| Who Is the Patient? | |
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| What Are Some Examples of Patient Fraud? | |
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| How Does the Patient Role Relate to Other Healthcare Continuum Players? | |
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| The Provider | |
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| Who Is the Provider? | |
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| What Are Some Examples of Provider Fraud? | |
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| How Does the Provider Role Relate to Other Healthcare Continuum Players? | |
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| The Payer | |
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| Who Is the Payer? | |
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| What Are Some Examples of Payer Fraud? | |
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| How Does the Payer Role Relate to Other Healthcare Continuum Players? | |
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| The Employer/Plan Sponsor | |
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| Who Is the Employer/Plan Sponsor? | |
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| What Are Some Examples of Employer/Plan Sponsor Fraud? | |
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| How Does the Employer/Plan Sponsor Role Relate to Other Healthcare Continuum Players? | |
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| The Vendor and the Supplier | |
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| Who Are the Vendor and the Supplier? | |
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| What Are Some Examples of Vendor and Supplier Fraud? | |
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| How Do the Vendor and Supplier Roles Relate to Other Healthcare Continuum Players? | |
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| The Government | |
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| Who Is the Government? | |
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| What Are Some Examples of Government Fraud? | |
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| How Does the Government Role Relate to Other Healthcare Continuum Players? | |
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| Organized Crime | |
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| Who Is Organized Crime? | |
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| How Does the Organized Crime Role Relate to Other Healthcare Continuum Players? | |
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| Market Players Overview: Implications for Prevention, Detection, and Investigation | |
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| Protected Health Information | |
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| Health Insurance Portability and Accountability Act of 1996 | |
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| Audit Guidelines in Using PHI | |
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| Protected Health Information Overview: Implications for Prevention, Detection, and Investigation | |
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| Health Information Pipelines | |
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| The Auditor's Checklist | |
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| What Are the Channels of Communication in a Health Information Pipeline? | |
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| The Patient | |
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| The Provider | |
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| The Payer | |
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| The Employer/Plan Sponsor | |
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| The Vendor/Supplier | |
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| The Government Plan Sponsor | |
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| Unauthorized Parties | |
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| HIP Overview: Implications for Prevention, Detection, and Investigation | |
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| Accounts Receivable Pipelines | |
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| Overview of Healthcare Reimbursement | |
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| Types of Reimbursement Models | |
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| Fee-for-Service Model | |
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| Prospective Model | |
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| Capitation-Structured Model | |
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| Data Contained in Accounts Receivable Pipelines | |
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| Accounts Receivable Pipelines by HCC Player | |
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| The Patient | |
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| The Provider | |
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| The Payer | |
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| The Employer/Plan Sponsor | |
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| Others | |
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| ARP Overview: Implications for Prevention, Detection, and Investigation | |
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| Operational Flow Activity | |
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| Operational Flow Activity Assessment | |
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| The Patient | |
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| The Provider | |
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| The Payer | |
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| The Employer | |
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| The "Other" | |
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| OFA Overview: Implications for Prevention, Detection, and Investigation | |
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| Product, Service, and Consumer Market Activity | |
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| Product Market Activity | |
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| Service Market Activity | |
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| Consumer Market Activity | |
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| PMA, SMA, and CMA Overview: Implications for Prevention, Detection, and Investigation | |
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| Data Management | |
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| Data Management | |
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| Market Example: Setting Up a Claims RDBMS | |
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| Data Management Overview: Implications for Prevention, Detection, and Investigation | |
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| References | |
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| Normal Infrastructure | |
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| Normal Profile of a Fraudster | |
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| What Types of People or Entities Commit Fraud? | |
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| What Is the Key Element of a Fraudster? | |
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| Anomalies and Abnormal Patterns | |
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| Normal Infrastructure Overview: Implications for Prevention, Detection, and Investigation | |
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| Normal Infrastructure and Anomaly Tracking Systems | |
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| The Patient | |
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| Sample Patient Fraud Scenarios | |
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| Data Management Considerations | |
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| The Untold Story | |
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| The Provider | |
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| Sample Provider Fraud Scenarios | |
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| Data Management Considerations | |
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| The Untold Story | |
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| The Payer | |
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| Sample Payer Fraud Scenarios | |
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| Data Management Considerations | |
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| The Untold Story | |
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| The Vendor/Other Parties | |
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| Sample Vendor/Other Fraud Scenarios | |
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| Data Management Considerations | |
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| The Untold Story | |
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| Organized Crime | |
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| Sample Organized Crime Fraud Scenarios | |
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| Data Management Considerations | |
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| The Untold Story | |
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| Normal Infrastructure and Anomaly Tracking Systems Overview: Implications for Prevention, Detection, and Investigation | |
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| Components of the Data Mapping Process | |
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| What Is Data Mapping? | |
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| Data Mapping Overview: Implications for Prevention, Detection, and Investigation | |
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| Components of the Data Mining Process | |
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| What Is Data Mining? | |
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| Data Mining in Healthcare | |
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| Components of the Data Mining Process within the HCC | |
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| Data Mining Overview: Implications for Prevention, Detection, and Investigation | |
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| Components of the Data Mapping and Data Mining Process | |
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| Forensic Application of Data Mapping and Data Mining | |
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| Data Mapping and Data Mining Overview: Implications for Prevention, Detection, and Investigation | |
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| Data Analysis Models | |
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| Detection Model | |
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| Pipeline Application | |
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| Detection Model Application | |
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| Investigation Model | |
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| Mitigation Model | |
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| Prevention Model | |
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| Response Model | |
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| Recovery Model | |
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| Data Analysis Model Overview: Implications for Prevention, Detection, and Investigation | |
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| Clinical Content Data Analysis | |
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| What Is SOAP? | |
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| The SOAP Methodology | |
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| Electronic Records | |
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| Analysis Considerations with Electronic Records | |
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| Narrative Discourse Analysis | |
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| Clinical Content Analysis Overview: Implications for Prevention, Detection, and Investigation | |
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| Profilers | |
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| Fraud and Profilers | |
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| Medical Errors and Profilers | |
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| Financial Errors and Profilers | |
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| Internal Audit and Profilers | |
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| Recovery and Profilers | |
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| Anomaly and Profilers | |
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| Fraud Awareness and Profilers | |
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| Profiler Overview: Implications for Prevention, Detection, and Investigation | |
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| Market Implications | |
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| The Myth | |
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| "Persistent" | |
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| "Persuasive" | |
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| "Unrealistic" | |
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| Market Overview: Implications for Prevention, Detection, and Investigation | |
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| Conclusions | |
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| Micromanagement Perspective | |
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| Macromanagement Perspective | |
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| Overview of Prevention, Detection, and Investigation | |
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| Index | |