Healthcare Fraud

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.

Statistics and Health Care Fraud: How to Save Billions helps the public to become more informed citizens through discussions of real world health care examples and fraud assessment applications. The author presents statistical and analytical methods used in health care fraud audits without requiring any mathematical background. The public suffers from health care overpayments either directly as patients or indirectly as taxpayers, and fraud analytics provides ways to handle the large size and complexity of these claims. The book starts with a brief overview of global healthcare systems such as U.S. Medicare. This is followed by a discussion of medical overpayments and assessment initiatives using a variety of real world examples. The book covers subjects as: • Description and visualization of medical claims data • Prediction of fraudulent transactions • Detection of excessive billings • Revealing new fraud patterns • Challenges and opportunities with health care fraud analytics Dr. Tahir Ekin is the Brandon Dee Roberts Associate Professor of Quantitative Methods in McCoy College of Business, Texas State University. His previous work experience includes a working as a statistician on health care fraud detection. His scholarly work on health care fraud has been published in a variety of academic journals including International Statistical Review, The American Statistician, and Applied Stochastic Models in Business and Industry. He is a recipient of the Texas State University 2018 Presidential Distinction Award in Scholar Activities and the ASA/NISS y-Bis 2016 Best Paper Awards. He has developed and taught courses in the areas of business statistics, optimization, data mining and analytics. Dr. Ekin also serves as Vice President of the International Society for Business and Industrial Statistics.

Who steals? An extraordinary range of folk -- from low-life hoods who sign on as Medicare or Medicaid providers equipped with nothing more than beepers and mailboxes, to drug trafficking organizations, organized crime syndicates, and even major hospital chains. In License to Steal, Malcolm K. Sparrow shows how the industry's defenses, which focus mostly on finding and correcting billing errors, are no match for such well orchestrated attacks. The maxim for thieves simply becomes "bill your lies correctly." Provided they do that, fraud perpetrators with any degree of sophistication can steal millions of dollars with impunity, testing payment systems carefully, and then spreading fraudulent billings widely enough across patient and provider accounts to escape detection. The kinds of highly automated, quality controlled claims processing systems that pervade the industry present fraud perpetrators with their favorite kind of target: rich, fast paying, transparent, utterly predictable check printing systems, with little threat of human intervention, and with the U.S. Treasury on the end of the electronic line. Sparrow picks apart the industry's response to the government's efforts to control this problem. The provider associations (well heeled and politically influential) have vociferously opposed almost every recent enforcement initiative, creating the unfortunate public impression that the entire health care industry is against effective fraud control. A significant segment of the industry, it seems, regards fraud and abuse not as a problem, but as a lucrative enterprise worth defending. Meanwhile, it remains a perfectly commonplace experience for patients or their relatives to examine a medical bill and discover that half of it never happened, or that; likewise, if patients then complain, they discover that no one seems to care, or that no one has the resources to do anything about it. Sparrow's research suggests that the growth of capitated managed care systems does not solve the problem, as many in the industry had assumed, but merely changes its form. The managed care environment produces scams involving underutilization, and the withholding of medical care schemes that are harder to uncover and investigate, and much more dangerous to human health. Having worked extensively with federal and state officials since the appearance of his first book on this subject, Sparrow is in a unique position to evaluate recent law enforcement initiatives. He admits the "war on fraud" is at least now engaged, but it is far from won.

The lack of well-documented, factual information on fraud, waste and corruption in the healthcare sector is an important ally for those who would seek to abuse healthcare systems for their own profit. Our lack of knowledge of the incidence, nature and extent of fraud, waste and corruption in healthcare is a threat to the establishment of effective counter-fraud strategies. It prevents those who finance healthcare provision from understanding in clear and quantifiable terms the need to invest resources into counter-fraud activities. As a consequence, fraud remains a matter of moral hazard and healthcare systems continue to suffer considerable financial damage, as well as all the associated consequences for the quality of care that patients receive. It was for these reasons that the 'European Healthcare Fraud and Corruption Network' (EHFCN) and the 'Dutch Healthcare Authority' (NZa, member of EHFCN) decided to collaborate to publish this book... --

U.S. health care is a $2.5 trillion system that accounts for more than 17 percent of the nation’s GDP. It is also highly susceptible to fraud. Estimates vary, but some observers believe that as much as 10 percent of all medical billing involves some type of fraud. In 2009, New York’s Medicaid fraud office recovered $283 million and obtained 148 criminal convictions. In July 2010, the U.S. Justice Department charged nearly 100 patients, doctors, and health care executives in five states of bilking the Medicare system out of more than $251 million through false claims for services that were medically unnecessary or never provided. These cases only hint at the scope of the problem. In Phantom Billing, Fake Prescriptions, and the High Cost of Medicine, Terry L. Leap takes on medical fraud and its economic, psychological, and social costs. Illustrated throughout with dozens of specific and often fascinating cases, this book covers a wide variety of crimes: kickbacks, illicit referrals, overcharging and double billing, upcoding, unbundling, rent-a-patient and pill-mill schemes, insurance scams, short-pilling, off-label marketing of pharmaceuticals, and rebate fraud, as well as criminal acts that enable this fraud (mail and wire fraud, conspiracy, and money laundering). After assessing the effectiveness of the federal laws designed to fight health care fraud and abuse—the antikickback statute, the Stark Law, the False Claims Act, HIPAA, and the food and drug laws—Leap suggests a number of ways that health care providers, consumers, insurers, and federal and state officials can bring health care fraud and abuse under control, thereby reducing the overall cost of medical care in America.

Some have estimated that healthcare fraud in the United States results in losses of approximately $80 billion a year. Although there are many books available that describe how to "detect" healthcare fraud, few address what must be done after the fraud is detected. Filling this need, Charles Piper’s Healthcare Fraud Investigation Guidebook details not only how to detect healthcare fraud, but also how to "investigate" and prove the wrongdoing to increase the likelihood of successful prosecution in court. The book starts by covering the history of healthcare insurance and the various types of fraud schemes. It presents Charles Piper’s unique approach to investigating (The Piper Method) which allows readers to conduct as many as 10 simultaneous investigations for each case. It emphasizes the importance of simultaneously searching for waste and abuse as well as systemic weaknesses and deficiencies that caused or contributed to the problem or wrongdoing under investigation and then make recommendations for improvement. It also provides: Questions to ask whistleblowers, complainants, employers, employees, and healthcare providers who are suspects Tips on investigative case planning, goals, and strategies Sample visual aids for use when briefing others about your investigative findings Guidance on presenting information obtained from healthcare investigations and on how to testify in court Techniques for uncovering previously undetected fraud The book includes a sample case study that walks readers through a mock case—from the time the case is received through the end. The case study demonstrates how to initiate, plan, and conduct a thorough and complete healthcare fraud investigation while incorporating Piper’s proven methodology. Sharing insights gained through Charles Piper’s decades of experience as a federal special agent and certified fraud examiner, the Healthcare Fraud Investigation Guidebook aims to revolutionize the way that healthcare fraud investigations are conducted. It provides the understanding you need to not only put a bandage on the problem of healthcare fraud, but to actually start curing the greed that is poisoning the healthcare industry.

The Canadian edition of The Little Black Book of Scams is a compact and easy to use reference guide filled with information Canadians can use to protect themselves against a variety of common scams. It debunks common myths about scams, provides contact information for reporting a scam to the correct authority, and offers a step-by-step guide for scam victims to reduce their losses and avoid becoming repeat victims. Consumers and businesses can consult The Little Black Book of Scams to avoid falling victim to social media and mobile phone scams, fake charities and lotteries, dating and romance scams, and many other schemes used to defraud Canadians of their money and personal information.