Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

The Patient

The patient’s role may fluctuate, depending on their role as a healthcare participant and their “payer” status. For example, a patient who has Medicaid is referred to as a “recipient” of a government sponsored state program. Within this context he or she receives covered, approved goods or services from other members of the P-HCC. This program is sponsored with funding from the federal level and respective state budgets. A patient who has Medicare or private healthcare coverage is referred to as a beneficiary. Medicare is funded by the federal budget. This patient also receives covered, approved goods or services from other members of the P-HCC in the context of their beneficiary program. Other programs are funded by their immediate sponsor. The accounts receivable pipeline (ARP) demonstrates the typical flow of services and reimbursements (see Chapter 11). Recall that, from a reimbursement perspective, the type of patient varies by their “payer” classification. Patients include those receiving health insurance from private employers, public employers, nonprofit exempt programs, government employee sponsored programs, their own independent purchases, or government programs such as Medicare, Medicaid, or a state or local municipalities program. Patients also include those without health insurance; of these patients, some have the financial means to pay for medical goods and services, and many do not.

Protected health information (PHI) is normally used to facilitate healthcare ...