Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Organized Crime

This leads us to our final player: OC. Fraud can occur in the context previously discussed by non-OC entities among players noted within the primary healthcare continuum. However, OC is attracted to healthcare due to its cash-rich environment and highly fragmented market, with minimal consequences in comparison to other illicit industries. The healthcare industry needs to stay alert to an increasing presence of organized criminal activity. OC is presented as a player from the perspective of its design, scope, and organization. OC is viewed as a third-tier market conflict, one that adds another layer of fragmentation. The OC designation as a P-HCC player is not to legitimize its presence but to appreciate its activity and impact. As you read the following section, keep the following categories in mind:

Tier One: Five Market Conflicts/Five Layers of Fragmentation

• The patient and the provider
• The patient and the payer
• The provider and the payer
• The payer and the employer (plan sponsor)
• The employer (plan sponsor) and the employee

Tier Two: Ten Market Conflicts/Ten Layers of Fragmentation

• The patient and the provider + vendors and suppliers
• The patient and the payer + vendors and suppliers
• The provider and the payer + vendors and suppliers
• The payer and the employer (plan sponsor) + vendors and suppliers
• The employer (plan sponsor) and the employee + vendors and suppliers

Tier Three: Fifteen Market Conflicts/Fifteen Layers of Fragmentation

• The patient and the provider ...