This book brings an unusual opportunity to explore the peculiarities of America's health care industry's approach to fraud control, when compared with the financial services sector, credit card companies, or the Internal Revenue Service—all of which have to defend themselves against fraud.
Introduction Part One: Understanding the Fraud-Control Challenge 1. The Pathology of Fraud Control 2. Particular Challenges in the Health Care Field Insurers as Socially Acceptable Targets 3. The Importance of Measurement Quality Controls in Claims Processing 4. Assessment of Fraud-Control Systems Claims Processing 5. The Antithesis of Modern Claims Processing Background Part Two: Current Developments 6. Electronic Claims Processing two Views of EDI's Effects on Fraud 7. Managed Care Part Three: Prescription for Progress 8. A Model Fraud-Control Strategy Components of a Model Fraud-Control Strategy 9. Detection Systems Emphasis on Detection Tools 10. Conclusion