Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Who Commits Healthcare Fraud?

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
• Vendors and suppliers providing services within the healthcare industry

They are found as employers providing benefit coverage; personnel employed by providers, payers, employers, or various vendors; and formal organized crime entities. The key element as to who they are is always defined by the defrauder’s action, not by his or her title or role. Most current publications dealing with healthcare fraud focus heavily on provider fraud. Limiting the focus on a particular player in the market merely creates opportunities for other players to concentrate their efforts on areas not receiving the same attention, thus potentially bleeding the system dry.

Looking at the people behind the scenes of major fraudulent behaviors requires a glimpse into the murky world of personality disorders. Understanding personality disorders may provide a better understanding of those most apt to follow the ethically challenged path. The National Institutes of Health (NIH) published statistics on personality disorders.Exhibit 1.1 ...