Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Healthcare Fraud Overview: Implications for Prevention, Detection, and Investigation

Job security for fraud auditors and investigators remains strong: The healthcare industry continues to have large amounts of cash running through it. It continues to attract the ethically challenged, whose stealing from the system shows no sign of stopping. Implications are many, particularly in the areas of prevention, detection, and investigation. These three areas require a detailed understanding of every legitimate and illegitimate player in the P-HCC, an ability to identify HIPs and ARPs, and an understanding of how PHI is utilized among all of the players.

It is important not only to understand how the P-HCC works, but also to follow healthcare market trends and how they impact fraud prevention, detection, and investigation. Fraud usually begins with a tip. That tip leads to an investigation. A comprehensive investigation requires you to understand the dynamics of the healthcare business. Healthcare fraud is often buried within the critical business functions. The purpose of the HIP and ARP process is to identify the functions that should be investigated. Detection will follow once an understanding has been achieved. Investigations and detections will identify vulnerabilities that in turn should be used as prevention tools. Prevention requires an understanding of how the healthcare entity functions and the cycle repeats itself.

With all aspects of auditing and investigations, keep current ...