Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Market Players Overview: Implications for Prevention, Detection, and Investigation

Healthcare is the prevention, treatment, provision, instruction, and management of illness and wellness through services offered by professionals, third-party entities, vendors, and suppliers. Historically, healthcare has been driven by illness models. Not until recently has the focus of wellness been integrated into the overall picture. The market, from a clinical perspective, is being driven by emerging wellness models. However, the reimbursement side is slowly catching up from a financial perspective. This market conflict impacts how services are generated and represented. As an industry, healthcare has been and will continue to be a demanded service, a high-expenditure service, and a continued target for waste, fraud, and abuse. The first step toward initiating or developing an audit program, fraud investigation, and subsequent internal controls is an understanding of this market’s history, changes, fragmented relationships, and market conflicts.

Both detection and prevention require a thorough understanding of the P-HCC, including how health information moves between players, how money moves, and the incentives that drive these relationships. In addition, due to the high volume of transactions, electronic tools are required to sift through large amounts of data.

Ultimately, all healthcare fraud investigations build on the ability to detect various fraud schemes. The remainder of this book is ...