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Healthcare Fraud: Auditing and Detection Guide Hardcover

ISBN-13: 978-1118179802 ISBN-10: 1118179803 Edition: 2nd

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Healthcare Fraud: Auditing and Detection Guide + Phantom Billing, Fake Prescriptions, and the High Cost of Medicine: Health Care Fraud and What to Do about It (The Culture and Politics of Health Care Work) + Healthcare Fraud War: 7 Keys To Victory
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Product Details

  • Hardcover: 340 pages
  • Publisher: Wiley; 2 edition (May 1, 2012)
  • Language: English
  • ISBN-10: 1118179803
  • ISBN-13: 978-1118179802
  • Product Dimensions: 9.1 x 6.1 x 1.3 inches
  • Shipping Weight: 1.2 pounds (View shipping rates and policies)
  • Average Customer Review: 4.3 out of 5 stars  See all reviews (6 customer reviews)
  • Amazon Best Sellers Rank: #269,196 in Books (See Top 100 in Books)

Editorial Reviews

From the Inside Flap

Healthcare Fraud Auditing and Detection Guide

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 Back Cover

Praise for the previous edition of Healthcare Fraud Auditing and Detection Guide

"Rebecca Busch has taken the cumbersome and complex subject of healthcare fraud and dissected it into well-defined parts. Her thoughtful discussion of how and where these parts provide opportunities for fraud—and how to detect and prevent it—is the essence of this work. This book is a must-read for anyone involved in the prevention, detection, and investigation of healthcare fraud."
—Robert M. Bryant President and Chief Executive Officer, National Insurance Crime Bureau

"Fraud continues to be a major subject area for internal auditors. Recent studies by the IIA show that healthcare audits are in the top ten subject areas audited. This book speaks to the necessary background that internal auditors should have when auditing healthcare activities so that they can have the necessary skills to look for and deal with potential fraudulent situations. I recommend this book be part of every internal audit department's library."
—Dave Richards, CIA, CPAPresident, The Institute of Internal Auditors

"The cost of healthcare fraud continues to escalate each year. It is a terrible burden on our already fragile healthcare system. This book will provide anti-fraud professionals with a valuable resource to help combat this critical problem."
—James D. Ratley, CFEPresident, Association of Certified Fraud Examiners

"Rebecca Busch's Healthcare Fraud: Auditing and Detection Guide fills a critical gap in anti-fraud literature. Written professionally and precisely, yet eminently readable, this book will be the 'go to' source for managers, academics, attorneys, auditors, and fraud examiners involved in healthcare. Healthcare Fraud: Auditing and Detection Guide demonstrates Ms. Busch's expertise and depth of knowledge in the area of healthcare fraud, and is testimony as to why she is such a sought-after speaker and educator."
—William J. Kresse, MS, JD, CPA, CFEAssistant Professor, Saint Xavier UniversityGraham School of Management2007 ACFE Educator of the Year

More About the Author

Rebecca is the founder of Medical Business Associates, Inc. - a healthcare consulting, audit and forensic services firm specializing in understanding how information and money move in healthcare.

To date Rebecca has over one hundred publications and presentations and twenty plus years of progressive achievement in the health care management industry. She is a registered nurse, a certified fraud examiner (CFE), health care fellow in financial management (FHFMA) and has a Masters Certificate in Case Management (CCM). She is a faculty member of the Association of Certified Fraud Examiners and makes frequent public speaker appearances.

Throughout her career she has been an advocate for individual patients who have found themselves "stuck" in the healthcare system. This eventually led to the creation of a Personal Health Record built on a case management framework that prevents both financial and medical errors.

Rebecca earned her BS in Nursing from Rush University in 1985 and her MBA from Lewis University in 1991.

Customer Reviews

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Most Helpful Customer Reviews

2 of 2 people found the following review helpful By Janet on April 29, 2013
Format: Hardcover
Rebecca Busch's Healthcare Fraud: Auditing and Detection Guide is an information and detailed explanation about a topic that is confusing and extensive. She explains healthcare fraud step-by-step, explaining the meaning of healthcare fraud, the players involved, the issues, consequences, and rules. Rebecca uses case examples to further aid in explaining the complex world of healthcare fraud. After reading this book, I realize how immense the healthcare industry is and how difficult a task it is to try and control all of the areas in which fraud can occur. Her book introduces a concise concept useful to anyone interested in working in the healthcare industry or just interested in protecting oneself against healthcare fraud.
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2 of 2 people found the following review helpful By B. Rabbi on April 29, 2013
Format: Hardcover
I have spent the past few years auditing healthcare transactions and have found several instances of potential fraud. But, after reading this book, I wonder what else I missed during those audits.

This book now serves as my comprehensive guide to healthcare audits and has greatly improved my audit and fraud examination skills. This is a definite must-read for both those new to this field and for seasoned pros!
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2 of 2 people found the following review helpful By dina l. stone on April 26, 2013
Format: Hardcover
This audit and detection guide was extremely effective in broadening my comprehension of how money and information move about the healthcare system. Understanding what is normal is so important in the field of healthcare fraud auditing because the auditor can then quickly pick out the red flags in order to resolve the issue at hand. I appreciate the information this book provides! Thank you Rebecca! Your knowledge and expertise are impressive! I am so glad someone is passionate enough about this subject to help others understand so they can, in turn, help others!
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