Download Healthcare Fraud: Auditing and Detection Guide by Rebecca S. Busch PDF

By Rebecca S. Busch

In line with deepest and public estimates, nearly $24 million is misplaced in line with hour to healthcare waste, fraud, and abuse. a must have reference for auditors, fraud investigators, and healthcare managers, Healthcare Fraud: Auditing and Detection consultant presents suggestions and methods that will help you spot—and prevent—the "red flags" of fraudulent job inside your company. Eminently readable, it's your “go-to” source, equipping you with the required abilities to seem for and take care of power fraudulent occasions.

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Extra resources for Healthcare Fraud: Auditing and Detection Guide

Sample text

In this scheme, patients participate in ‘‘renting’’ their bodies to fraudulent providers, who then perform unnecessary procedures to submit to the patients’ benefit plans for reimbursement. How Does the Patient Role Relate to Other Healthcare Continuum Players? In initiating a fraud scheme, a patient can act independently or collude with any of the other market players in the HCC, for example, by having a provider misrepresent a diagnosis. The patient also could participate in an organized criminal enterprise such as one involved in staging an accident to submit a series of false claims and litigation.

Do not limit your imagination or develop tunnel vision when it comes to healthcare fraud. Fraud is committed anywhere and by anyone. The list includes providers; insured patients; individuals, both domestic and foreign; approvers (employees) who pay claims to themselves or friends; rings, or a group of criminals who commit healthcare fraud; nonproviders, or nonmedical, nonrelated healthcare players who create fraud schemes; payers, agents, and personnel; and vendors and suppliers providing services within the healthcare industry.

An employer is a person or entity that hires employees. As part of its employment offering, an employer provides wages to the employees in exchange for their labor. In addition to wages, an employer may offer employees healthcare benefits. Our previous discussion included the history of this offering. The specific type of employer in our first example is a selfinsured employer. This type of plan sponsor is typically a third party in the process. Historically, a self-insured employer is not directly involved with the claims processing of its employees’ healthcare services.

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