Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Fraud and Profilers

As this book has pointed out repeatedly, the primary motivating factor in fraud is the pursuit of money. However, fraud can be motivated by other factors. In the application of these profilers, other intentions will materialize. The first profiler is for fraud; see Exhibit 22.1.

Exhibit 22.1 Fraud Profiler

Exhibit 22.1 represents a graphic decision tree, a visual presentation of the logic discussed in this book. The following case discussion represents a potential 340 B program abuse. Note the data sets in Exhibit 22.2.

Exhibit 22.2 340 B Program Abuse Case Sample

340 B Programs Who: Federal Register, 71(138), July 19, 2006, notices. What: Limitation on prices of drugs by covered entities. When: A manufacturer sells covered outpatient drugs to eligible entities. Such a manufacturer must sign a pharmaceutical pricing agreement with the Secretary of the U.S. Department of Health and Human Services, in which the manufacturer agrees to charge a price for covered outpatient drugs that will not exceed an amount determined under a statutory formula. Why: Compliance requirements with Section 340B(a)(5). Where: Outpatient activity with 340 B program drugs. 340 B Part B Who: Covered entity What: Prohibits from reselling or otherwise transferring a discounted drug to a person who is not a patient of the entity When: Inventory management Why: 340 B program abuse ...