{"product_id":"healthcare-fraud-isbn-9781118179802","title":"Healthcare Fraud","description":"\u003cb\u003eAn invaluable tool equipping healthcare professionals, auditors, and investigators to detect every kind of healthcare fraud\u003c\/b\u003e  \u003cp\u003eAccording 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, \u003ci\u003eHealthcare Fraud, Second Edition\u003c\/i\u003e 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.\u003c\/p\u003e \u003cul\u003e \u003cli\u003eIncludes new chapters on primary healthcare, secondary healthcare, information\/data management and privacy, damages\/risk management, and transparency\u003c\/li\u003e \u003cli\u003eOffers comprehensive guidance on auditing and fraud detection for healthcare providers and company healthcare plans\u003c\/li\u003e \u003cli\u003eExamines the necessary background that internal auditors should have when auditing healthcare activities\u003c\/li\u003e \u003c\/ul\u003e \u003cp\u003eManaging 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 \u003ci\u003eHealthcare Fraud, Second Edition\u003c\/i\u003e and get the valuable guidance you need to help combat this critical problem.\u003c\/p\u003e \u003cp\u003ePreface xiii\u003c\/p\u003e \u003cp\u003eAcknowledgments xvii\u003c\/p\u003e \u003cp\u003e\u003cb\u003eChapter 1 Introduction to Healthcare Fraud 1\u003c\/b\u003e\u003c\/p\u003e \u003cp\u003eWhat Is Healthcare Fraud? 2\u003c\/p\u003e \u003cp\u003eHealthcare Fraud in the United States 4\u003c\/p\u003e \u003cp\u003eHealthcare Fraud in International Markets 4\u003c\/p\u003e \u003cp\u003eWhat Does Healthcare Fraud Look Like? 5\u003c\/p\u003e \u003cp\u003eWho Commits Healthcare Fraud? 9\u003c\/p\u003e \u003cp\u003eWhat Is Healthcare Fraud Examination? 11\u003c\/p\u003e \u003cp\u003eThe Primary Healthcare Continuum: An Overview 13\u003c\/p\u003e \u003cp\u003eHealthcare Fraud Overview: Implications for Prevention, Detection, and Investigation 14\u003c\/p\u003e \u003cp\u003eNotes 17\u003c\/p\u003e \u003cp\u003e\u003cb\u003eChapter 2 Defining Market Players within the Primary Healthcare Continuum 19\u003c\/b\u003e\u003c\/p\u003e \u003cp\u003eThe Patient 19\u003c\/p\u003e \u003cp\u003eThe Provider 24\u003c\/p\u003e \u003cp\u003eThe Payer 42\u003c\/p\u003e \u003cp\u003eThe Employer\/Plan Sponsor 48\u003c\/p\u003e \u003cp\u003eThe Vendor and the Supplier 49\u003c\/p\u003e \u003cp\u003eThe Government 50\u003c\/p\u003e \u003cp\u003eOrganized Crime 51\u003c\/p\u003e \u003cp\u003eMarket Players Overview: Implications for Prevention, Detection, and Investigation 53\u003c\/p\u003e \u003cp\u003e\u003cb\u003eChapter 3 Continuum Audit and Investigative Model 57\u003c\/b\u003e\u003c\/p\u003e \u003cp\u003eMarket Understanding 58\u003c\/p\u003e \u003cp\u003eThe Primary Healthcare Continuum (P-HCC) 58\u003c\/p\u003e \u003cp\u003eThe Secondary Healthcare Continuum (S-HCC) 58\u003c\/p\u003e \u003cp\u003eThe Information Healthcare Continuum (I-HCC) 62\u003c\/p\u003e \u003cp\u003eThe Consequence Healthcare Continuum (C-HCC) 63\u003c\/p\u003e \u003cp\u003eThe Transparency Healthcare Continuum (T-HCC) 65\u003c\/p\u003e \u003cp\u003eThe Rules Based Healthcare Continuum (R-HCC) 66\u003c\/p\u003e \u003cp\u003eAudit Continuum Models Overview: Implications for Prevention, Detection, and Investigation 68\u003c\/p\u003e \u003cp\u003eNotes 68\u003c\/p\u003e \u003cp\u003e\u003cb\u003eChapter 4 Secondary Healthcare Continuum 69\u003c\/b\u003e\u003c\/p\u003e \u003cp\u003eThe Secondary Healthcare Continuum (S-HCC) 71\u003c\/p\u003e \u003cp\u003eAudit Continuum Models Overview: Implications for Prevention, Detection, and Investigation 75\u003c\/p\u003e \u003cp\u003eNotes 75\u003c\/p\u003e \u003cp\u003e\u003cb\u003eChapter 5 Information Healthcare Continuum 77\u003c\/b\u003e\u003c\/p\u003e \u003cp\u003eCase Study Dr. Traveler—Recap 77\u003c\/p\u003e \u003cp\u003eContinuum Audit Progression—Recap 78\u003c\/p\u003e \u003cp\u003eThe Information Healthcare Continuum (I-HCC) 78\u003c\/p\u003e \u003cp\u003eAudit Continuum Models Overview: Implications for Prevention, Detection, and Investigation 83\u003c\/p\u003e \u003cp\u003eNotes 84\u003c\/p\u003e \u003cp\u003e\u003cb\u003eChapter 6 Consequence Healthcare Continuum 85\u003c\/b\u003e\u003c\/p\u003e \u003cp\u003eCase Study Dr. Traveler—Recap 85\u003c\/p\u003e \u003cp\u003eContinuum Audit Progression—Recap 86\u003c\/p\u003e \u003cp\u003eThe Consequence Healthcare Continuum (C-HCC) 86\u003c\/p\u003e \u003cp\u003eEconomic Business Impact 88\u003c\/p\u003e \u003cp\u003eServiceability and Service Integrity 89\u003c\/p\u003e \u003cp\u003eService, Medical, and Financial Errors 90\u003c\/p\u003e \u003cp\u003eAudit Continuum Models Overview: Implications for Prevention, Detection, and Investigation 90\u003c\/p\u003e \u003cp\u003e\u003cb\u003eChapter 7 Transparency Healthcare Continuum 93\u003c\/b\u003e\u003c\/p\u003e \u003cp\u003eCase Study Dr. Traveler—Recap 93\u003c\/p\u003e \u003cp\u003eContinuum Audit Progression—Recap 94\u003c\/p\u003e \u003cp\u003eThe Transparency Healthcare Continuum (T-HCC) 95\u003c\/p\u003e \u003cp\u003eAudit Continuum Models Overview: Implications for Prevention, Detection, and Investigation 96\u003c\/p\u003e \u003cp\u003e\u003cb\u003eChapter 8 Rules Based Healthcare Continuum 97\u003c\/b\u003e\u003c\/p\u003e \u003cp\u003eCase Study Dr. Traveler—Recap 98\u003c\/p\u003e \u003cp\u003eThe Rules Based Healthcare Continuum (R-HCC) 99\u003c\/p\u003e \u003cp\u003eContinuum Audit Progression—Summary 104\u003c\/p\u003e \u003cp\u003eAudit Continuum Models Overview: Implications for Prevention, Detection, and Investigation 106\u003c\/p\u003e \u003cp\u003eNotes 107\u003c\/p\u003e \u003cp\u003e\u003cb\u003eChapter 9 Protected Health Information 109\u003c\/b\u003e\u003c\/p\u003e \u003cp\u003eHealth Insurance Portability and Accountability Act of 1996 109\u003c\/p\u003e \u003cp\u003eAudit Guidelines in Using Protected Health Information 110\u003c\/p\u003e \u003cp\u003eProtected Health Information Overview: Implications for Prevention, Detection, and Investigation 113\u003c\/p\u003e \u003cp\u003e\u003cb\u003eChapter 10 Health Information Pipelines 115\u003c\/b\u003e\u003c\/p\u003e \u003cp\u003eThe Auditor’s Checklist 115\u003c\/p\u003e \u003cp\u003eWhat Are the Channels of Communication in a Health Information Pipeline? 116\u003c\/p\u003e \u003cp\u003eUnauthorized Parties 125\u003c\/p\u003e \u003cp\u003eHealth Information Pipelines Overview: Implications for Prevention, Detection, and Investigation 126\u003c\/p\u003e \u003cp\u003e\u003cb\u003eChapter 11 Accounts Receivable Pipelines 129\u003c\/b\u003e\u003c\/p\u003e \u003cp\u003eOverview of Healthcare Reimbursement 130\u003c\/p\u003e \u003cp\u003eTypes of Reimbursement Models 131\u003c\/p\u003e \u003cp\u003eData Contained in Accounts Receivable Pipelines 135\u003c\/p\u003e \u003cp\u003eAccounts Receivable Pipelines by Healthcare Continuum Player 135\u003c\/p\u003e \u003cp\u003eAccounts Receivable Pipelines Overview: Implications for Prevention, Detection, and Investigation 154\u003c\/p\u003e \u003cp\u003e\u003cb\u003eChapter 12 Operational Flow Activity 157\u003c\/b\u003e\u003c\/p\u003e \u003cp\u003eOperational Flow Activity Assessment 157\u003c\/p\u003e \u003cp\u003eOperational Flow Activity Overview: Implications for Prevention, Detection, and Investigation 163\u003c\/p\u003e \u003cp\u003e\u003cb\u003eChapter 13 Product, Service, and Consumer Market Activity 165\u003c\/b\u003e\u003c\/p\u003e \u003cp\u003eProduct Market Activity 165\u003c\/p\u003e \u003cp\u003eService Market Activity 167\u003c\/p\u003e \u003cp\u003eConsumer Market Activity 167\u003c\/p\u003e \u003cp\u003eProduct, Service, and Consumer Market Activity Overview: Implications for Prevention, Detection, and Investigation 175\u003c\/p\u003e \u003cp\u003e\u003cb\u003eChapter 14 Data Management 177\u003c\/b\u003e\u003c\/p\u003e \u003cp\u003eData Management 177\u003c\/p\u003e \u003cp\u003eMarket Example: Setting Up a Claims Relational Database Management System 181\u003c\/p\u003e \u003cp\u003eData Management Overview: Implications for Prevention, Detection, and Investigation 182\u003c\/p\u003e \u003cp\u003eReferences 182\u003c\/p\u003e \u003cp\u003e\u003cb\u003eChapter 15 Normal Infrastructure 185\u003c\/b\u003e\u003c\/p\u003e \u003cp\u003eNormal Profile of a Fraudster 185\u003c\/p\u003e \u003cp\u003eAnomalies and Abnormal Patterns 188\u003c\/p\u003e \u003cp\u003eContinuum Audit and Investigative Model 188\u003c\/p\u003e \u003cp\u003eNormal Infrastructure Overview: Implications for Prevention, Detection, and Investigation 189\u003c\/p\u003e \u003cp\u003e\u003cb\u003eChapter 16 Normal Infrastructure and Anomaly Tracking Systems 191\u003c\/b\u003e\u003c\/p\u003e \u003cp\u003eThe Patient 191\u003c\/p\u003e \u003cp\u003eThe Provider 194\u003c\/p\u003e \u003cp\u003eThe Payer 198\u003c\/p\u003e \u003cp\u003eThe Vendor\/Other Parties 201\u003c\/p\u003e \u003cp\u003eOrganized Crime 205\u003c\/p\u003e \u003cp\u003eNormal Infrastructure and Anomaly Tracking Systems Overview: Implications for Prevention, Detection, and Investigation 207\u003c\/p\u003e \u003cp\u003eNotes 207\u003c\/p\u003e \u003cp\u003e\u003cb\u003eChapter 17 Components of the Data Mapping Process 209\u003c\/b\u003e\u003c\/p\u003e \u003cp\u003eWhat Is Data Mapping? 209\u003c\/p\u003e \u003cp\u003eData Mapping Overview: Implications for Prevention, Detection, and Investigation 213\u003c\/p\u003e \u003cp\u003e\u003cb\u003eChapter 18 Components of the Data Mining Process 215\u003c\/b\u003e\u003c\/p\u003e \u003cp\u003e\u003cb\u003eChapter 19 What Is Data Mining? 215\u003c\/b\u003e\u003c\/p\u003e \u003cp\u003eData Mining Overview: Implications for Prevention, Detection, and Investigation 219\u003c\/p\u003e \u003cp\u003eComponents of the Data Mapping and Data Mining Process 221\u003c\/p\u003e \u003cp\u003eForensic Application of Data Mapping and Data Mining 224\u003c\/p\u003e \u003cp\u003eData Mapping and Data Mining Overview: Implications for Prevention, Detection, and Investigation 226\u003c\/p\u003e \u003cp\u003e\u003cb\u003eChapter 20 Data Analysis Models 227\u003c\/b\u003e\u003c\/p\u003e \u003cp\u003eDetection Model 227\u003c\/p\u003e \u003cp\u003eInvestigation Model 230\u003c\/p\u003e \u003cp\u003eMitigation Model 233\u003c\/p\u003e \u003cp\u003ePrevention Model 235\u003c\/p\u003e \u003cp\u003eResponse Model 240\u003c\/p\u003e \u003cp\u003eRecovery Model 244\u003c\/p\u003e \u003cp\u003eData Analysis Model Overview: Implications for Prevention, Detection, and Investigation 253\u003c\/p\u003e \u003cp\u003e\u003cb\u003eChapter 21 Clinical Content Data Analysis 255\u003c\/b\u003e\u003c\/p\u003e \u003cp\u003eWhat Is SOAP? 256\u003c\/p\u003e \u003cp\u003eThe SOAP Methodology 257\u003c\/p\u003e \u003cp\u003eElectronic Records 270\u003c\/p\u003e \u003cp\u003eAnalysis Considerations with Electronic Records 273\u003c\/p\u003e \u003cp\u003eNarrative Discourse Analysis 277\u003c\/p\u003e \u003cp\u003eClinical Content Analysis Overview: Implications for Prevention, Detection, and Investigation 284\u003c\/p\u003e \u003cp\u003e\u003cb\u003eChapter 22 Profilers 287\u003c\/b\u003e\u003c\/p\u003e \u003cp\u003eFraud and Profilers 287\u003c\/p\u003e \u003cp\u003eMedical Errors and Profilers 291\u003c\/p\u003e \u003cp\u003eFinancial Errors and Profilers 296\u003c\/p\u003e \u003cp\u003eInternal Audit and Profilers 300\u003c\/p\u003e \u003cp\u003eRecovery and Profilers 302\u003c\/p\u003e \u003cp\u003eAnomaly and Profilers 303\u003c\/p\u003e \u003cp\u003eFraud Awareness and Profilers 304\u003c\/p\u003e \u003cp\u003eProfiler Overview: Implications for Prevention, Detection, and Investigation 305\u003c\/p\u003e \u003cp\u003e\u003cb\u003eChapter 23 Market Implications 307\u003c\/b\u003e\u003c\/p\u003e \u003cp\u003eThe Myth 307\u003c\/p\u003e \u003cp\u003e“Persistent” 310\u003c\/p\u003e \u003cp\u003e“Persuasive” 310\u003c\/p\u003e \u003cp\u003e“Unrealistic” 312\u003c\/p\u003e \u003cp\u003eMarket Overview: Implications for Prevention, Detection, and Investigation 313\u003c\/p\u003e \u003cp\u003e\u003cb\u003eChapter 24 Conclusions 315\u003c\/b\u003e\u003c\/p\u003e \u003cp\u003eMicromanagement Perspective 315\u003c\/p\u003e \u003cp\u003eMacromanagement Perspective 326\u003c\/p\u003e \u003cp\u003eOverview of Prevention, Detection, and Investigation 327\u003c\/p\u003e \u003cp\u003eAbout the Author 333\u003c\/p\u003e \u003cp\u003eIndex 335\u003c\/p\u003e   \u003cp\u003e\u003cb\u003eREBECCA SALTIEL BUSCH, RN, MBA, CCM, CFE, CHS-III, CPC, FHFMA, FIALCP,\u003c\/b\u003e 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 \u003ci\u003eBusiness Ledger\u003c\/i\u003e 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.     \u003c\/p\u003e\u003cp\u003e\u003cb\u003eHEALTHCARE FRAUD Auditing and Detection Guide, Second Edition\u003c\/b\u003e \u003c\/p\u003e\u003cp\u003eThe 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. \u003c\/p\u003e\u003cp\u003eNow completely updated, this \u003ci\u003eSecond Edition\u003c\/i\u003e of \u003ci\u003eHealthcare Fraud: Auditing and Detection Guide\u003c\/i\u003e 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. \u003c\/p\u003e\u003cp\u003e\u003ci\u003eHealthcare Fraud, Second Edition\u003c\/i\u003e features: \u003c\/p\u003e\u003cul\u003e \u003cli\u003eSix 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.\u003c\/li\u003e \u003cli\u003eHow data mapping and mining can be used as a key tool to maximize the effectiveness of fraud investigations\u003c\/li\u003e \u003cli\u003eInsightful discussion from a number of perspectives; clinical, research, internal audit, investigative, data intelligence, and forensic\u003c\/li\u003e \u003cli\u003eA behind-the-scenes look at internal controls and anomaly tracking systems for ongoing monitoring and surveillance\u003c\/li\u003e \u003cli\u003eBuilding blocks for understanding the entire healthcare market and its respective players\u003c\/li\u003e \u003cli\u003eCases and methodologies providing actual audit and investigative tools\u003c\/li\u003e \u003cli\u003eUseful outlines of healthcare fraud prevention, detection, and investigation methods\u003c\/li\u003e \u003c\/ul\u003e \u003cp\u003eSharpen your skills as an auditor or investigator to identify incontrovertible truth with the visionary guidance found in \u003ci\u003eHealthcare Fraud, Second Edition\u003c\/i\u003e.\u003c\/p\u003e","brand":"Wiley","offers":[{"title":"Default Title","offer_id":47989352497381,"sku":"NP9781118179802","price":79.0,"currency_code":"USD","in_stock":false}],"thumbnail_url":"\/\/cdn.shopify.com\/s\/files\/1\/1842\/7735\/files\/9781118179802.jpg?v=1761783781","url":"https:\/\/k12savings.com\/products\/healthcare-fraud-isbn-9781118179802","provider":"K12savings","version":"1.0","type":"link"}