Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Consumer Market Activity

CMA is identifying the behavior patterns of the patient and their families. This includes purchase, choice, and selection decisions by the consumer and the influences driving them. The continued analysis should incorporate lining up how the patient makes the consumer choice with the product and services being provided by the provider. What was the source of the patients associated with the 340 B drugs? Were they recruited? Were they referred? If referred, does any type of financial relationship exist with the referring party? In continuing this example, we progress by adding the CMA component to the audit process (see Exhibit 13.3).

Exhibit 13.3 Product, Service, and Consumer Market Activity

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

The data sample that initiated this discussion included a provider who was a rheumatologist. In this example, the rheumatologist’s clinic was approved by the Department of Health and Human Services to receive 340 B program drugs. Within the list of medications was a series of cancer treatment drugs. The doctor created files on these patients at his clinic to meet the perceived documentation standard of the 340 B program; however, the patients were treated at other clinics in other states by oncologists. The “treatment” is defined as the actual receipt of the 340 B medications at a different facility by a ...