Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Chapter 4

Secondary Healthcare Continuum

Facts are stubborn things.

–Ronald Reagan (1911–2004)

Any case, review, or audit is always about the facts. The ability to recognize, identify, discern, and corroborate information, at times, can prove to be a challenge. Without the correct or appropriate data, the results can take you down the wrong path or, worse, leave you spinning in a maze with no exit in sight. The continuum audit model is about removing the stubbornness of hidden data. Once you have that data, the next step is just as important—benchmarking. When conducting an audit or an investigation, the notion of “abnormal,” or the idea of looking for anomalies, is often benchmarked against some type of standard, rule, policy, or contract as noted in the S-HCC. In this chapter, we begin to apply the model via a case study and build upon it over the next few chapters.

In review, the primary healthcare continuum was discussed in detail in Chapter 2. An overview application of the entire continuum audit model with subpart considerations was provided in Chapter 3. The next few chapters are going to focus on how to build the continuum audit model with a case that will be referred to as “Dr. Traveler.”

Case History: Dr. Traveler is a licensed MD with a philanthropic edge in providing free healthcare examinations to the underinsured. The primary healthcare continuum market players in this case example are defined as a licensed medical doctor, working in a free standing clinic not affiliated ...