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
|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
|• ||Experience and understanding of the health care system|
Questia, a part of Gale, Cengage Learning. www.questia.com
Book title: 101 Careers in Nursing.
Contributors: Jeanne M. Novotny - Editor, Doris T. Lippman - Editor, Nicole K. Sanders - Editor, Joyce J. Fitzpatrick - Editor.
Place of publication: New York.
Publication year: 2003.
Page number: 58.
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