Healthcare Fraud Auditing and Detection Guide
By Rebecca S. Busch
The National Health Care Anti-Fraud Association estimates that healthcare fraud collectively costs Americans between $60 billion and $100 billion a year. Although the immediate targets and victims of that fraud are private health payers and government-funded health plans, all of us ultimately pay for the crime – through higher health insurance premiums (or fewer benefits) for employers and individuals, higher taxes, and higher insurance co-payments for privately and publicly insured patients.
It is therefore no surprise of the amount of resources that are dedicated to the prevention, detection and investigation of healthcare fraud within organizations. This has been a difficult area for auditors to cover because of the specialized nature of healthcare and the insurance industry as well as new privacy laws. The Healthcare Fraud Auditing and Detection Guide walks the auditor through the ins and outs of this high profile audit area. After providing an introduction to healthcare fraud, the author defines the critical market players in the healthcare continuum; patients, providers, and payers. As most auditors are familiar with the term “follow the money” the book provides model audit health information pipelines or HIP’s for each of the players as well as the monetary implications. The HIP identifies the route and use of health information and is critical to understanding how to audit healthcare costs. The next section of the book covers the reimbursement process which is driven by rules and contractual provisions. The final chapters cover the analysis methodologies to detect healthcare fraud including forensic techniques for data mapping and data mining, data analysis models for detection, investigation, mitigation, prevention, response and recovery.
The author has taken a complex subject and put it into a simple to understand language for auditors and fraud investigators. The checklists and case studies add to the value of this desk top reference. This book will fill a gap in your professional library on an important subject that all auditors will have to consider when developing current and future audit plans.