Unit 10: Advanced Topics in 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 Topics in Healthcare Fraud Investigation #
a course that covers specialized techniques and methods used in the investigation of healthcare fraud. The course covers topics such as data analysis, forensic accounting, and legal and ethical issues in healthcare fraud investigation.
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. The law is designed to prevent healthcare providers from offering or accepting bribes or kickbacks in exchange for patient referrals.
Compliance Program #
a set of internal policies, procedures, and controls that an organization puts in place to ensure that it is following all applicable laws, regulations, and standards. In the context of healthcare fraud investigation, a compliance program can help an organization prevent, detect, and respond to fraud, waste, and abuse.
Data Analysis #
the process of inspecting, cleaning, transforming, and modeling data to discover useful information, draw conclusions, and support decision-making. In healthcare fraud investigation, data analysis can be used to identify patterns and trends that may indicate fraudulent activity.
Digital Forensics #
the process of uncovering and interpreting electronic data for use in a legal case. In healthcare fraud investigation, digital forensics may be used to recover deleted emails, analyze computer logs, or examine electronic health records.
False Claims Act (FCA) #
a federal law that prohibits the submission of false or fraudulent claims to the government. The FCA is often used in healthcare fraud investigations to hold healthcare providers accountable for fraudulent billing practices.
Forensic Accounting #
the use of accounting principles and techniques to investigate fraud and other financial crimes. In healthcare fraud investigation, forensic accounting may be used to examine financial records, trace the flow of funds, or identify suspicious transactions.
Health Insurance Portability and Accountability Act (HIPAA) #
a federal law that protects the privacy and security of patients' medical information. HIPAA sets standards for the use, disclosure, and safeguarding of protected health information (PHI).
Identity Theft #
the unauthorized use of someone else's personal information, such as their name, social security number, or credit card information, to commit fraud or other crimes. In healthcare, identity theft can be used to obtain medical care, prescription medications, or medical equipment fraudulently.
Medicaid Fraud Control Unit (MFCU) #
a state agency that is responsible for investigating and prosecuting Medicaid fraud. MFCUs are funded by the federal government and are required to meet certain performance standards.
Medicare Fraud Strike Force (MFSF) #
a joint initiative between the Department of Justice and the Department of Health and Human Services that targets healthcare fraud in specific geographic locations. The MFSF uses data analysis and other investigative techniques to identify and prosecute healthcare providers who are committing fraud.
Qui Tam Lawsuit #
a legal action brought by a private citizen, known as a "relator," on behalf of the government. Qui tam lawsuits are often used in healthcare fraud investigations to hold healthcare providers accountable for fraudulent billing practices. If the lawsuit is successful, the relator may be eligible for a portion of the recovered funds.
Waste #
the overuse or misuse of healthcare resources, resulting in unnecessary costs. Waste can take many forms, such as unnecessary tests, procedures, or treatments, or the provision of medical equipment or supplies that are not medically necessary.
Whistleblower #
a person who reports suspected wrongdoing or illegal activity within an organization. Whistleblowers play an important role in identifying and preventing healthcare fraud, and are protected by laws such as the False Claims Act.