101 Careers in Nursing

By Jeanne M. Novotny; Doris T. Lippman et al. | Go to book overview
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Fraud and Abuse Investigator
1. Basic description—A fraud and abuse investigator investigates health care fraud and abuse charges using such techniques as information technology and statistics to identify outlier practice behaviors. They are employed by government agencies investigating abuse or fraud, or by independent consulting groups who perform this service through contacts with government agencies. This allows investigators to recognize and look more closely at providers who are practicing in an unusual manner. Investigations are often aggressive and involve working with the FBI and U.S. States Attorneys to obtain justice. Cases are also reported to local medical and professional boards. The most common types of fraud and abuse are upcoding (for example, a practitioner billing for a 60-minute office visit when it was only a 20-minute visit); unbundling (for example, usually dealing with CPT coding, like a blood test being billed under a combined code, then one or more tests from that composite test gets billed individually); charging for services not rendered; and performing unnecessary procedures or tests.
2. Educational requirements—RN preparation and an undergraduate degree are the baseline on which to add additional skills, certifications, and expertise. Graduate degree in business is desired.
3. Core competencies/skills needed:
Computer literacy. Cases are often complex with myriad databases requiring an understanding of information technology
A broad background in nursing with up-to-date clinical knowledge
Experience and understanding of the health care system

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101 Careers in Nursing
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