Documentation Analysis
Expert-defined terms from the Advanced Certificate in Healthcare Fraud Case Studies course at London School of Business and Administration. Free to read, free to share, paired with a globally recognised certification pathway.
Advanced Certificate in Healthcare Fraud Case Studies #
a professional certification program that provides in-depth knowledge and analysis of real-world healthcare fraud cases.
Audit Trail #
a record of system activities that enables the tracking of user actions and changes to data. It is used to ensure data integrity, detect errors, and investigate fraud.
Billing Fraud #
a type of healthcare fraud that involves submitting false or inflated claims to obtain unauthorized payments. This includes upcoding, unbundling, and phantom billing.
Clinical Laboratory Improvement Amendments (CLIA) #
a set of federal regulations that govern laboratory testing and require laboratories to be certified by the Centers for Medicare & Medicaid Services (CMS).
Coding Systems #
standardized systems used to assign codes to diagnoses, procedures, and services for billing and data analysis purposes. Examples include the International Classification of Diseases (ICD) and the Current Procedural Terminology (CPT).
Compliance Program #
a set of policies, procedures, and internal controls designed to prevent, detect, and respond to violations of laws, regulations, and organizational policies.
Data Mining #
the process of analyzing large datasets to identify patterns, trends, and anomalies. It is used in healthcare fraud detection to identify suspicious billing patterns and outlier providers.
Documentation Analysis #
the process of reviewing medical records, billing documents, and other supporting evidence to determine the medical necessity, appropriateness, and accuracy of healthcare services billed.
False Claims Act (FCA) #
a federal law that prohibits the submission of false or fraudulent claims to the government. It includes whistleblower provisions that allow individuals to report fraud and receive a share of any recovery.
Fraud Hotline #
a confidential reporting mechanism that allows individuals to report suspected fraud, waste, and abuse.
Healthcare Fraud #
the intentional deception or misrepresentation of healthcare services, diagnoses, or billing for the purpose of financial gain.
Identity Theft #
the unauthorized use of someone else's personal information, such as their name, Social Security number, or insurance policy number, to obtain healthcare services or benefits.
Kickbacks #
the offering, soliciting, or receiving of anything of value in exchange for referrals of healthcare services or patients.
Medicaid Fraud Control Unit (MFCU) #
a state agency responsible for investigating and prosecuting Medicaid fraud.
Medicare Fraud Strike Force (MFSF) #
a federal task force composed of investigators and prosecutors from various law enforcement agencies that targets healthcare fraud.
Phantom Billing #
a type of billing fraud that involves submitting claims for services that were not provided or were not medically necessary.
Stark Law #
a federal law that prohibits self-referrals, or the referral of patients for certain designated healthcare services to entities in which the referring physician has a financial interest.
Upcoding #
a type of billing fraud that involves submitting claims using codes that reflect a higher level of service or complexity than was actually provided.
Whistleblower #
an individual who reports suspected fraud, waste, or abuse, often as a protected activity under federal or state laws.
ZPIC #
Zone Program Integrity Contractors (ZPICs) are contractors hired by the Centers for Medicare & Medicaid Services (CMS) to investigate and prevent healthcare fraud, waste, and abuse. ZPICs have the authority to conduct audits, review medical records and other documentation, and investigate suspected fraud. They are responsible for identifying and stopping fraudulent activities, recovering overpayments, and referring cases for criminal prosecution. ZPICs operate in specific geographic zones and work closely with other law enforcement agencies, such as the Department of Health and Human Services Office of Inspector General (HHS-OIG) and the Department of Justice (DOJ), to combat healthcare fraud.