Healthcare Fraud: Auditing and Detection Guide by Rebecca S. Busch

By Rebecca S. Busch

In accordance with deepest and public estimates, nearly $24 million is misplaced consistent with hour to healthcare waste, fraud, and abuse. a must have reference for auditors, fraud investigators, and healthcare managers, Healthcare Fraud: Auditing and Detection consultant offers tips and methods that will help you spot—and prevent—the "red flags" of fraudulent job inside of your company. Eminently readable, it's your “go-to” source, equipping you with the required talents to seem for and care for strength fraudulent events.

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The follow-up notifications should be in writing and include information on the reason for the determination and instructions on utilizing an external party for further appeals. The external appeals process should have several characteristics. First, it should be available to the consumer after all internal processes have been the patient 21 exhausted. The only exceptions are with urgent cases of acute care needs. ’’ As with the initial appeal process, the professionals involved need to be appropriately credentialed with respect to the subject of the treatment in question.

Each fraud scheme generated by the ethically challenged is different, too. The individual, professional, or entity involved reacts to the ‘‘music’’ or healthcare event in part using whatever unique experiences, understandings, emotional states, and levels of sophistication are possessed at the time the event is experienced. T 17 18 chapter 2 defining market players The Patient Who Is the Patient? A patient is any person who receives medical attention or some type of clinical care or treatment, usually from a physician or other type of medical professional.

The report focuses also on the role of technology. Its authors believe that technology can play a critical role in detecting fraud and abuse and can help to pave the way toward prevention. Although technology cannot eliminate the fraud problem, it can significantly minimize fraud and abuse and ultimately reduce healthcare fraud losses. The use of advanced analytics software built into the national health information network (NHIN) is critical to fraud loss reduction. Information available via the NHIN must comply with all federal and state laws.

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