Healthcare Fraud: Auditing and Detection Guide - Hardcover

Busch, Rebecca S.

Hardcover

ISBN 10: 1118179803 ISBN 13: 9781118179802

Publisher: Wiley, 2012

Synopsis

An invaluable tool equipping healthcare professionals, auditors, and investigators to detect every kind of healthcare fraud

According to private and public estimates, billions of dollars are lost per hour to healthcare waste, fraud, and abuse. A must-have reference for auditors, fraud investigators, and healthcare managers, Healthcare Fraud, Second Edition provides tips and techniques to help you spot―and prevent―the "red flags" of fraudulent activity within your organization. Eminently readable, it is your "go-to" resource, equipping you with the necessary skills to look for and deal with potential fraudulent situations.

• Includes new chapters on primary healthcare, secondary healthcare, information/data management and privacy, damages/risk management, and transparency
• Offers comprehensive guidance on auditing and fraud detection for healthcare providers and company healthcare plans
• Examines the necessary background that internal auditors should have when auditing healthcare activities

Managing the risks in healthcare fraud requires an understanding of how the healthcare system works and where the key risk areas are. With health records now all being converted to electronic form, the key risk areas and audit process are changing. Read Healthcare Fraud, Second Edition and get the valuable guidance you need to help combat this critical problem.

About this title

About the Author

REBECCA SALTIEL BUSCH, RN, MBA, CCM, CFE, CHS-III, CPC, FHFMA, FIALCP, has a passion to create educated, conscientious healthcare consumers. Recent leadership and professional recognitions include the 2011 Chicago United's Business Leaders of Color Award, 2010 Finalist for the Enterprising Women of the Year Award, and 2009 Recipient of the Influential Women in Business Award by the Business Ledger in partnership with NAWBO. Her entrepreneurial, professional, driven career has resulted in various proprietary audit platforms in multi-market verticals in healthcare, and authorship of over 200 articles, books, and presentations to consumers, government, corporate, and professional entities. Recognized as an expert in her field, she has provided public and forensic expert testimony and participated in public policy discussions and the development of best practice standards. Rebecca currently has seven U.S. design patents and one U.S patent focused on efficacy, risk, FWB, and revenue management within healthcare.

From the Back Cover

HEALTHCARE FRAUD Auditing and Detection Guide, Second Edition

The world of healthcare fraud is much more than just pocketing money or a corporate asset. Stealing the very essence of human life, healthcare fraud ranges from false claims by perpetrators who perform needless procedures that disable and kill, to rogue Internet pharmacies. Once limited to petty thefts and deliberately incorrect billing, the world of healthcare fraud has become one of high-tech, highly skilled, educated, and professional perpetrators.

Now completely updated, this Second Edition of Healthcare Fraud: Auditing and Detection Guide is the must-have reference for auditors, fraud investigators, and healthcare managers, revealing proven tips and techniques to help you spot the "red flags" of fraudulent activity, as well as the steps you need to take when fraud is suspected. Author Rebecca Busch a pioneer in conducting technology and process-enabled audits of healthcare claims and processing presents comprehensive guidance on auditing and fraud detection for healthcare providers and company healthcare plans.

Healthcare Fraud, Second Edition features:

• Six new chapters detailing a comprehensive audit model encompassing primary, secondary, information, damages, transparency, and rules-based continuum. Detailed analytic pipelines within each continuum extrapolating components of PHI, dollars involved, operations, products, services, and type of consumer. This integration is the secret sauce to any successful investigation.
• How data mapping and mining can be used as a key tool to maximize the effectiveness of fraud investigations
• Insightful discussion from a number of perspectives; clinical, research, internal audit, investigative, data intelligence, and forensic
• A behind-the-scenes look at internal controls and anomaly tracking systems for ongoing monitoring and surveillance
• Building blocks for understanding the entire healthcare market and its respective players
• Cases and methodologies providing actual audit and investigative tools
• Useful outlines of healthcare fraud prevention, detection, and investigation methods

Sharpen your skills as an auditor or investigator to identify incontrovertible truth with the visionary guidance found in Healthcare Fraud, Second Edition.

From the Inside Flap

HEALTHCARE FRAUD Auditing and Detection Guide, Second Edition

The world of healthcare fraud is much more than just pocketing money or a corporate asset. Stealing the very essence of human life, healthcare fraud ranges from false claims by perpetrators who perform needless procedures that disable and kill, to rogue Internet pharmacies. Once limited to petty thefts and deliberately incorrect billing, the world of healthcare fraud has become one of high-tech, highly skilled, educated, and professional perpetrators.

Now completely updated, this Second Edition of Healthcare Fraud: Auditing and Detection Guide is the must-have reference for auditors, fraud investigators, and healthcare managers, revealing proven tips and techniques to help you spot the "red flags" of fraudulent activity, as well as the steps you need to take when fraud is suspected. Author Rebecca Busch—a pioneer in conducting technology and process-enabled audits of healthcare claims and processing—presents comprehensive guidance on auditing and fraud detection for healthcare providers and company healthcare plans.

Healthcare Fraud, Second Edition features:

• Six new chapters detailing a comprehensive audit model encompassing primary, secondary, information, damages, transparency, and rules-based continuum. Detailed analytic pipelines within each continuum extrapolating components of PHI, dollars involved, operations, products, services, and type of consumer. This integration is the secret sauce to any successful investigation.
• How data mapping and mining can be used as a key tool to maximize the effectiveness of fraud investigations
• Insightful discussion from a number of perspectives; clinical, research, internal audit, investigative, data intelligence, and forensic
• A behind-the-scenes look at internal controls and anomaly tracking systems for ongoing monitoring and surveillance
• Building blocks for understanding the entire healthcare market and its respective players
• Cases and methodologies providing actual audit and investigative tools
• Useful outlines of healthcare fraud prevention, detection, and investigation methods

Sharpen your skills as an auditor or investigator to identify incontrovertible truth with the visionary guidance found in Healthcare Fraud, Second Edition.

Edition details

• Publisher: Wiley
• Publication date: 2012
• Language: English
• ISBN 10: 1118179803
• ISBN 13: 9781118179802
• Binding: Hardcover
• Edition number: 2
• Number of pages: 368