Unit 1: Introduction to Healthcare Fraud Investigation
Expert-defined terms from the Advanced Certificate in Healthcare Fraud Investigation Best Practices 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 Investigation Best Practices #
A certificate program that provides students with advanced knowledge and skills in healthcare fraud investigation, with a focus on best practices for detecting, preventing, and prosecuting fraud.
Anti #
kickback Statute (AKS): A federal law that prohibits the exchange of anything of value in return for referrals of federal healthcare program business, such as Medicare or Medicaid.
Billing fraud #
A type of healthcare fraud that involves falsely billing for services or procedures that were not provided, were unnecessary, or were upcoded (billed at a higher level than actually provided).
Clinical Laboratory Improvement Amendments (CLIA) #
Federal regulations that establish quality standards for all laboratory testing performed on humans in the US, except research laboratories.
Compliance program #
A set of internal policies, procedures, and controls designed to prevent and detect violations of laws and regulations applicable to an organization.
Confidentiality #
The practice of protecting sensitive or private information from unauthorized access or disclosure.
Conviction #
A judgment of guilt against a criminal defendant.
Data mining #
The process of analyzing large datasets to discover patterns, trends, and anomalies that may indicate fraudulent activity.
Deep web #
The portion of the internet that is not indexed by search engines and requires special software or authorization to access.
Delivery system #
The network of providers, hospitals, clinics, and other entities that deliver healthcare services to patients.
Digital forensics #
The process of collecting, analyzing, and preserving electronic evidence for use in investigations or legal proceedings.
Electronic Health Record (EHR) #
A digital version of a patient's medical history that is stored and shared electronically among authorized providers.
False Claims Act (FCA) #
A federal law that imposes civil and criminal penalties on individuals or entities that submit false or fraudulent claims to the government.
Federal Bureau of Investigation (FBI) #
The primary federal law enforcement agency responsible for investigating healthcare fraud and other crimes.
Fraud #
The intentional deception or misrepresentation of facts for the purpose of financial gain.
Health Insurance Portability and Accountability Act (HIPAA) #
Federal regulations that protect the privacy and security of patients' medical information.
Identity theft #
The unauthorized use of another person's personal information, such as their name, social security number, or credit card information, for fraudulent purposes.
Internal Revenue Service (IRS) #
The federal agency responsible for collecting taxes and enforcing tax laws.
Kickback #
An illegal payment made in exchange for referrals of healthcare program business.
Medicaid #
A joint federal-state program that provides healthcare coverage to low-income individuals and families.
Medicare #
A federal program that provides healthcare coverage to individuals over the age of 65 and certain disabled individuals.
Mental health parity #
The principle that mental health benefits should be equivalent to medical and surgical benefits in terms of coverage and access.
Money laundering #
The process of making illegally-gained proceeds appear legitimate through a series of transactions.
Office of Inspector General (OIG) #
The agency within the US Department of Health and Human Services responsible for detecting and preventing fraud, waste, and abuse in the healthcare system.
Pharmacy benefit manager (PBM) #
A third-party administrator of prescription drug programs for health insurers, self-insured employers, and other payers.
Physician self #
referral: The practice of referring patients to healthcare services in which the referring physician has a financial interest.
Qui tam #
A legal provision that allows private citizens to file lawsuits on behalf of the government and receive a portion of the recovered funds.
Stark Law #
Federal laws that prohibit physician self-referral for certain designated health services paid for by Medicare.
Telehealth #
The use of telecommunication and information technologies to provide healthcare services remotely.
Upcoding #
The practice of billing for a more expensive service or procedure than was actually provided.
Whistleblower #
An individual who reports suspected illegal activity within an organization.
Wire fraud #
A federal crime involving the use of interstate wire communications to further a fraudulent scheme.