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