Healthcare Fraud Investigation Guidebook

Author: Charles E. Piper
Publisher: CRC Press
ISBN: 1498752616
Format: PDF
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Some have estimated that healthcare fraud in the United States results in losses of approximately $80 billion a year. Although there are many books available that describe how to "detect" healthcare fraud, few address what must be done after the fraud is detected. Filling this need, Charles Piper’s Healthcare Fraud Investigation Guidebook details not only how to detect healthcare fraud, but also how to "investigate" and prove the wrongdoing to increase the likelihood of successful prosecution in court. The book starts by covering the history of healthcare insurance and the various types of fraud schemes. It presents Charles Piper’s unique approach to investigating (The Piper Method) which allows readers to conduct as many as 10 simultaneous investigations for each case. It emphasizes the importance of simultaneously searching for waste and abuse as well as systemic weaknesses and deficiencies that caused or contributed to the problem or wrongdoing under investigation and then make recommendations for improvement. It also provides: Questions to ask whistleblowers, complainants, employers, employees, and healthcare providers who are suspects Tips on investigative case planning, goals, and strategies Sample visual aids for use when briefing others about your investigative findings Guidance on presenting information obtained from healthcare investigations and on how to testify in court Techniques for uncovering previously undetected fraud The book includes a sample case study that walks readers through a mock case—from the time the case is received through the end. The case study demonstrates how to initiate, plan, and conduct a thorough and complete healthcare fraud investigation while incorporating Piper’s proven methodology. Sharing insights gained through Charles Piper’s decades of experience as a federal special agent and certified fraud examiner, the Healthcare Fraud Investigation Guidebook aims to revolutionize the way that healthcare fraud investigations are conducted. It provides the understanding you need to not only put a bandage on the problem of healthcare fraud, but to actually start curing the greed that is poisoning the healthcare industry.

Healthcare Fraud

Author: Rebecca S. Busch
Publisher: John Wiley & Sons
ISBN: 1118240251
Format: PDF, ePub, Docs
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An invaluable tool equipping healthcare professionals, auditors, and investigators to detect every kind of healthcare fraud According to private and public estimates, billions of dollars are lost per hour to healthcare waste, fraud, and abuse. A must-have reference for auditors, fraud investigators, and healthcare managers, Healthcare Fraud, Second Edition provides tips and techniques to help you spot—and prevent—the "red flags" of fraudulent activity within your organization. Eminently readable, it is your "go-to" resource, equipping you with the necessary skills to look for and deal with potential fraudulent situations. Includes new chapters on primary healthcare, secondary healthcare, information/data management and privacy, damages/risk management, and transparency Offers comprehensive guidance on auditing and fraud detection for healthcare providers and company healthcare plans Examines the necessary background that internal auditors should have when auditing healthcare activities Managing the risks in healthcare fraud requires an understanding of how the healthcare system works and where the key risk areas are. With health records now all being converted to electronic form, the key risk areas and audit process are changing. Read Healthcare Fraud, Second Edition and get the valuable guidance you need to help combat this critical problem.

Contract and Procurement Fraud Investigation Guidebook

Author: Charles E. Piper
Publisher: Routledge
ISBN: 1351697218
Format: PDF, ePub, Docs
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Contract and procurement fraud, collusion, and corruption are worldwide problems. Such wrongdoing causes federal, state, and local governments, as well as private-sector corporations and businesses, to lose funds and profits, while the wrongdoers unjustly benefit. Bid riggers conspire to eliminate fair and open competition and unjustly increase prices, allowing some to monopolize industries. Too often, contracting officials and others responsible for placing orders or awarding contracts compromise their integrity and eliminate fair and open competition to favor vendors offering bribes or gifts. This results in unfair playing fields for vendors and causes financial losses for businesses, government agencies, and taxpayers. Charles Piper’s Contract and Procurement Fraud and Corruption Investigation Guidebook educates readers on fraud and corruption schemes that occur before, during, and after contracts are awarded. This book teaches not only how to identify such wrongdoing, but also how to investigate it and prevent reoccurrence. Piper shares the Piper Method of Conducting Thorough and Complete Investigations, his innovative and proven method of investigating contract and procurement fraud, and demonstrates its principles with personal, on-the-job examples (which he calls "War Stories") woven throughout the text. Intended for criminal justice students, as well as investigators, auditors, examiners, business owners, policy-makers, and other professionals potentially affected by fraud, this book is a must-read guide to effective procurement and contract fraud investigations from inception to testimony.

Expert Fraud Investigation

Author: Tracy L. Coenen
Publisher: John Wiley & Sons
ISBN: 9780470447840
Format: PDF, ePub, Mobi
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A fraud investigation is aimed at examining evidence to determine if a fraud occurred, how it happened, who was involved, and how much money was lost. Investigations occur in cases ranging from embezzlement, to falsification of financial statements, to suspicious insurance claims. Expert Fraud Investigation: A Step-by-Step Guide provides all the tools to conduct a fraud investigation, detailing when and how to investigate. This guide takes the professional from the point of opening an investigation, selecting a team, gathering data, and through the entire investigation process. Business executives, auditors, and security professionals will benefit from this book, and companies will find this a useful tool for fighting fraud within their own organizations.

Investigator and Fraud Fighter Guidebook

Author: Charles E. Piper
Publisher: John Wiley & Sons
ISBN: 1118878507
Format: PDF, ePub, Mobi
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Get federal investigative insight and guidance on conducting thorough investigations and case-building The ability to conduct thorough and effective investigations is a skill that has become increasingly in-demand across many industries. At the same time, investigative resources are dwindling as markets recede. Regulation and financial hurdles impede traditional investigation processes. Even seasoned professionals are finding themselves overtasked or lacking the experience to pursue the types of cases that are accumulating. In Investigator and Fraud Fighter Guidebook: Operation War Stories, author Charles E. Piper, CFE provides insight and guidance on how to conduct thorough and complete investigations while juggling a caseload. Piper served over 30 years in law enforcement-including 20 as an award-winning Federal Special Agent-Criminal Investigator. His wide array of experience allows him to lend a high-level perspective to the art and science of professional investigations of criminal, civil, and administrative cases. In the book, Piper provides guidance on conducting thorough and complete investigations (even with fewer resources) and spotting red flags that often indicate big-picture problems. Piper also shows how to: Identify the suspect's other wrongful acts (similar and otherwise) Identify similar wrongful acts committed by others, and predict future occurrences Identify systemic weaknesses, waste, and abuse Identify changes and corrections necessary to prevent future occurrences The book includes Piper's real-life investigative examples to illustrate important concepts. Whether the matter is public, private, or military, the same basic investigative principles apply. Things that may seem totally unrelated may hold the keys that crack the cases. The Investigator and Fraud Fighter Guidebook: Operation War Stories provides the acumen and judgment required to pick up on these clues and successfully conclude investigations.

Fraud Analytics Using Descriptive Predictive and Social Network Techniques

Author: Bart Baesens
Publisher: John Wiley & Sons
ISBN: 1119133122
Format: PDF, Docs
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Detect fraud earlier to mitigate loss and prevent cascading damage Fraud Analytics Using Descriptive, Predictive, and Social Network Techniques is an authoritative guidebook for setting up a comprehensive fraud detection analytics solution. Early detection is a key factor in mitigating fraud damage, but it involves more specialized techniques than detecting fraud at the more advanced stages. This invaluable guide details both the theory and technical aspects of these techniques, and provides expert insight into streamlining implementation. Coverage includes data gathering, preprocessing, model building, and post–implementation, with comprehensive guidance on various learning techniques and the data types utilized by each. These techniques are effective for fraud detection across industry boundaries, including applications in insurance fraud, credit card fraud, anti–money laundering, healthcare fraud, telecommunications fraud, click fraud, tax evasion, and more, giving you a highly practical framework for fraud prevention. It is estimated that a typical organization loses about 5% of its revenue to fraud every year. More effective fraud detection is possible, and this book describes the various analytical techniques your organization must implement to put a stop to the revenue leak. Examine fraud patterns in historical data Utilize labeled, unlabeled, and networked data Detect fraud before the damage cascades Reduce losses, increase recovery, and tighten security The longer fraud is allowed to go on, the more harm it causes. It expands exponentially, sending ripples of damage throughout the organization, and becomes more and more complex to track, stop, and reverse. Fraud prevention relies on early and effective fraud detection, enabled by the techniques discussed here. Fraud Analytics Using Descriptive, Predictive, and Social Network Techniques helps you stop fraud in its tracks, and eliminate the opportunities for future occurrence.

Forensic Analytics

Author: Mark Nigrini
Publisher: John Wiley & Sons
ISBN: 9781118087633
Format: PDF, ePub, Mobi
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Discover how to detect fraud, biases, or errors in your data using Access or Excel With over 300 images, Forensic Analytics reviews and shows how twenty substantive and rigorous tests can be used to detect fraud, errors, estimates, or biases in your data. For each test, the original data is shown with the steps needed to get to the final result. The tests range from high-level data overviews to assess the reasonableness of data, to highly focused tests that give small samples of highly suspicious transactions. These tests are relevant to your organization, whether small or large, for profit, nonprofit, or government-related. Demonstrates how to use Access, Excel, and PowerPoint in a forensic setting Explores use of statistical techniques such as Benford's Law, descriptive statistics, correlation, and time-series analysis to detect fraud and errors Discusses the detection of financial statement fraud using various statistical approaches Explains how to score locations, agents, customers, or employees for fraud risk Shows you how to become the data analytics expert in your organization Forensic Analytics shows how you can use Microsoft Access and Excel as your primary data interrogation tools to find exceptional, irregular, and anomalous records.

License to Steal

Author: Malcolm K. Sparrow
Publisher: Basic Books
ISBN: 0813368103
Format: PDF, Kindle
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Explains how fraud, abuse, and theft robs the U.S. health-care system of more than $100 billion each year, discussing current controls and how they fail, the government's attempts to solve the problem, the perpetrators responsible--ranging from organized crime syndicates to hospital systems--and what needs to be done to stop it.

Corruption and the Secret of Law

Author: Gerhard Anders
Publisher: Routledge
ISBN: 1351948342
Format: PDF, ePub
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This volume presents an anthropological perspective on the hidden continuities between corruption and law. The authors argue that the two opposites, corruption and law, are inextricably linked - with the possibility of the former already inscribed into the latter. Taking a critical stance towards the normative good governance agenda spearheaded by institutions such as Transparency International and the World Bank, this volume argues that by uncritically depicting corruption as an absolute evil, these anti-corruption programs disregard the close relationship that exists between corruption and state power. Addressing various aspects of a complex and ambivalent phenomenon, Corruption and the Secret of Law draws on studies from different parts of the world including Burundi, China, Indonesia, Italy, Japan, Mexico and the USA and provides a valuable resource for students, researchers and policy-makers working in this area.