Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

The Transparency Healthcare Continuum (T-HCC)

T-HCC Definition

The fifth continuum integrates risk. This analysis is based on the transparency continuum (T-HCC). T-HCC (Exhibit 3.5) analysis identifies transparency issues that could exist for any number of reasons and affect any number of market player processes. Transparency issues can pertain to both business and personal disclosures and are driven by social assumptions, laws and legislation, and limitations of access due to technology, contracts, and other intentional and unintentional constraints.

Exhibit 3.5 Transparency Healthcare Continuum (T-HCC)

Source: Medical Business Associates, Inc. (www.mbaaudit.com)

Transactions among market participants occurring during operational processes by any of the market players noted in the P-HCC are guided by market participant “motives” and market “rules” that directly affect the accuracy and quality of information. Market participant “motives” might be influenced by business, personal, governmental, public policy, and/or political pressures. Market “rules” can be formal, informal, and/or variable in nature and may cause one or a number of market participants to be exposed to risk because of a lack of accurate or complete information.

The management of healthcare transactions and claims is an enormous challenge due to:

• Ever-increasing medical costs
• Voluminous, conflicting, complicated ...