Healthcare Fraud: Auditing and Detection Guide, 2nd Edition

Overview of Prevention, Detection, and Investigation

Providing logical solutions to complex problems is a novel concept that deserves our constant effort. It requires the political honesty and transparency that the market is continually fighting. Waste, fraud, and abuse in the healthcare market are unlike that in any other industry. How many consumers do you know who walk into a used car dealership with their guard up? How many walk into the emergency room with a loved one with their guard up? When fraud, waste, or abuse occurs in healthcare, the damage goes beyond the financial theft and greed. It becomes a personal assault on an individual, physically and emotionally.

The previously discussed primary healthcare continuum (P-HCC) is noted in Exhibit 24.1. Potential contracts are demonstrated in this exhibit. A healthcare episode moving through this continuum can be easily impacted by up to nine contractual obligations. That is nine incentives for profit, nine different business operations, nine opportunities for manipulation, and nine layers of insulation. Of course, the final player, organized crime, is waiting below to tap into any one of these routes to perpetuate a scheme.

Exhibit 24.1 Primary Healthcare Continuum (P-HCC)

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

If I were to pick one thing to change, it would be to make all of the dotted line arrows transparent. ...