Book description
An invaluable tool equipping healthcare professionals, auditors, and investigators to detect every kind of healthcare fraud
According to private and public estimates, billions of dollars are lost per hour to healthcare waste, fraud, and abuse. A must-have reference for auditors, fraud investigators, and healthcare managers, Healthcare Fraud, Second Edition provides tips and techniques to help you spot—and prevent—the "red flags" of fraudulent activity within your organization. Eminently readable, it is your "go-to" resource, equipping you with the necessary skills to look for and deal with potential fraudulent situations.
Includes new chapters on primary healthcare, secondary healthcare, information/data management and privacy, damages/risk management, and transparency
Offers comprehensive guidance on auditing and fraud detection for healthcare providers and company healthcare plans
Examines the necessary background that internal auditors should have when auditing healthcare activities
Managing the risks in healthcare fraud requires an understanding of how the healthcare system works and where the key risk areas are. With health records now all being converted to electronic form, the key risk areas and audit process are changing. Read Healthcare Fraud, Second Edition and get the valuable guidance you need to help combat this critical problem.
Table of contents
- Cover
- Title Page
- Copyright
- Dedication
- Preface
- Acknowledgments
-
Chapter 1: 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?
- What Is Healthcare Fraud Examination?
- The Primary Healthcare Continuum: An Overview
- Healthcare Fraud Overview: Implications for Prevention, Detection, and Investigation
- Notes
- Chapter 2: Defining Market Players within the Primary Healthcare Continuum
-
Chapter 3: 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
- Chapter 4: Secondary Healthcare Continuum
- Chapter 5: Information Healthcare Continuum
-
Chapter 6: 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
- Chapter 7: Transparency Healthcare Continuum
- Chapter 8: Rules Based Healthcare Continuum
- Chapter 9: Protected Health Information
- Chapter 10: Health Information Pipelines
- Chapter 11: Accounts Receivable Pipelines
- Chapter 12: Operational Flow Activity
- Chapter 13: Product, Service, and Consumer Market Activity
- Chapter 14: Data Management
- Chapter 15: Normal Infrastructure
- Chapter 16: Normal Infrastructure and Anomaly Tracking Systems
- Chapter 17: Components of the Data Mapping Process
- Chapter 18: Components of the Data Mining Process
- Chapter 19: Components of the Data Mapping and Data Mining Process
- Chapter 20: Data Analysis Models
- Chapter 21: Clinical Content Data Analysis
- Chapter 22: Profilers
- Chapter 23: Market Implications
- Chapter 24: Conclusions
- About the Author
- Index
Product information
- Title: Healthcare Fraud: Auditing and Detection Guide, 2nd Edition
- Author(s):
- Release date: May 2012
- Publisher(s): Wiley
- ISBN: 9781118179802
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