Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Operational Flow Activity Overview: Implications for Prevention, Detection, and Investigation

Incontrovertible truth is obtained by utilizing a methodology that will cut through any blind spots and expunge information in a “pure” form. Purity of evidence is critical for an effective audit and investigation. Malice and ignorance can be mitigated by following the collection guidelines checklist:

Internal communications

External communications

Critical communication components

• Electronic/technology platforms
• Paper
• Verbal
• Facsimile
• People and entities (business, philanthropic, social, political, governmental)
• Systems/vendor relationships
• Product or service output
• Social media
• Intranet, extranet, Internet

This collection checklist should be followed by the three-layered operational data collection tools of pipelines. The audit and investigation begins by recognizing the layered process of the HIPs. The HIP is the process of identifying the health information involved. This is followed by the ARP, collecting the respective monetary transaction. Finally, the next parallel is collecting the OFA, which is the operational flow activity alongside the HIP and the ARP.

When these pipelines ...