Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Investigation Model

An investigation involves ascertaining whether various activities or statements are true. It is an investigation of inquiries. In the case of Dr. Healer, a statement or data set of, “Dr. Foreign, staff physician, an unlicensed doctor, was on staff for $5 per hour,” would create an opportunity for corroboration via appropriate evidence. Evidence to collect may include confirmation of license status, educational training, clinic marketing materials, and payroll records.

The statement, “High percentage of complicated visits; Dr. Healer generated bills while traveling in Europe,” needs to be broken down as well. The breakdown activity is a subtle, but very important point with investigations. An investigation is like an a la carte menu at a high-end restaurant. Each item and issue needs to be broken down into a singular form and investigated within that space. Then it is all pulled back together. This book places a great deal of emphasis on data aggregation, because healthcare is such a fragmented and segmented marketplace. The presented models walk through the activity of aggregation. When it comes to investigations, the aggregation component is utilized. However, each data element needs to be investigated individually and then within the aggregation of data sets.

The data from Dr. Healer set has two distinct pipeline issues and operational factors for consideration. The first part of the statement, “high percentage of complicated visits,” represents an ARP issue; ...