Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Chapter 3

Continuum Audit and Investigative Model

If the facts don’t fit the theory, change the facts.

–Albert Einstein (1879–1955)

The first edition of this book tackled the general framework of collecting relevant data to initiate a healthcare audit or investigation. Since that publication the model of the “healthcare continuum” was utilized to effectively identify and understand market players. The model has been applied to ongoing casework. Each time a “road block” was encountered that was “new” or “different,” the model was updated. Further, the behaviors and attributes involved during a review or case were further delineated and expanded. My publication “Electronic Health Records: An Audit and Internal Control Guide”1 provided a discussion on attributes of the Information Healthcare Continuum. Audits and investigations are driven by collecting, processing, and analyzing data. Due to the level of fragmentation in healthcare information systems a separate book was dedicated specifically to electronic health records issues.

This book integrates the original three continuums with three new continuums. The result is a total of six separate identifiable categories. The development of all six continuum models provides a more defined framework to serve as a guide to discern a complete review of relevant facts. In the first edition of this publication, a reference was made to the “healthcare continuum” as an opportunity to identify and understand relevant healthcare market players. ...