Cover -- Half Tilte -- Title -- Copyright -- Contents -- Foreword -- Preface -- Acknowledgments -- Introduction -- PART ONE Understanding the Fraud-Control Challenge -- 1 The Pathology of Fraud Control -- Essential Character of Fraud Control -- What Constitutes an Effective Fraud-Control System? --...

Ausführliche Beschreibung

Bibliographische Detailangaben

1. Verfasser:	Sparrow, Malcolm K. 1956- (VerfasserIn)
Weitere Verfasser:	Chiles, Lawton Mainor 1930-1998 (VerfasserIn eines Geleitwortes)
Format:	Buch
Sprache:	English
Veröffentlicht:	London ; New York Routledge 2018
Schlagworte:	Delivery of Health Care > United States Fraud > United States Medical care > Corrupt practices > United States Medicare fraud Scientific Misconduct > United States Kriminalität Gesundheitswesen USA
Zusammenfassung:	Cover -- Half Tilte -- Title -- Copyright -- Contents -- Foreword -- Preface -- Acknowledgments -- Introduction -- PART ONE Understanding the Fraud-Control Challenge -- 1 The Pathology of Fraud Control -- Essential Character of Fraud Control -- What Constitutes an Effective Fraud-Control System? -- How Bad Can Things Get Before the System Responds? -- 2 Particular Challenges In the Health Care Field -- Insurers as Socially Acceptable Targets -- Health Care Fraud Schemes Not Self-Revealing -- Separation Between Administrative Budget and "Funds -- Respectability of the Health Care Profession -- Unclear Distinctions Between Fraud, Abuse, Overutilization, and Other Activities -- 3 The Importance of Measurement -- Quality Controls in Claims Processing -- Surveys of Fraud Cases -- Random Mailing of EOMBs -- Implications of the Absence of Measurement -- How Measurement Changes the Nature of the Discussion-Fraud in the IRS Refund Program -- Why Measurement Is Not Done -- Resource Allocation, in the Absence of Measurement -- 4 Assessment of Fraud-Control Systems -- Claims Processing -- Claims Examination and Development -- Prepayment Medical Review -- An Experiment in Automated "Claims Examination -- Surprising Lack of Fraud Awareness -- Post-Utilization Review -- Audits -- Special Investigative Units -- Lack of Coordinated Control Strategy -- 5 The Antithesis of Modern Claims Processing -- Background -- Evidence of Success -- What Company X Does Differently -- Lessons for the Industry -- PART TWO Current Developments -- 6 Electronic Claims Processing -- Two Views of EDI's Effects on Fraud -- Popular Misconceptions -- Prosecutorial Difficulties -- Detection Difficulties -- Absence of Common Sense in Claims Reviews -- Three New Threats -- Can Technology Provide Appropriate Safeguards? -- Automated Prevention": A Fatally Flawed Vision
Beschreibung:	First published 1996 by Westview Press
Beschreibung:	xv, 240 Seiten
ISBN:	9780367009717 9780367159580