Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

What Does Healthcare Fraud Look Like?

It is important to appreciate that healthcare is a dynamic and segmented market among parties that deliver or facilitate the delivery of health information, healthcare resources, and the financial transactions that move along all components. To fully appreciate what healthcare fraud looks like, it is important to understand traditional and nontraditional players. The patient is the individual who actually receives a healthcare service or product. The provider is an individual or entity that delivers or executes the healthcare service or product. The payer is the entity that processes the financial transaction. The payer may be the party that takes on risk or manages risk for a plan sponsor providing the covered services. The plan sponsor is the party that funds the transaction. Plan sponsors include private self-insurance programs, employer-based premium programs, and government programs such as Medicare and Medicaid. A vendor is any entity that provides a professional service or materials used in the delivery of patient care.

What does healthcare fraud look like from the patient’s perspective? The patient may submit a false claim with no participation from any other party. The patient may exaggerate a workers’ compensation claim or allege that an injury took place at work when in fact it occurred outside of work. The patient may participate in collusive fraudulent behavior with other parties. A second party may be a physician who fabricates ...