License to Steal: How Fraud Bleeds America's Health Care System

By Malcolm K. Sparrow | Go to book overview

INDEX
ABC's 20/20, 22
Adverse Actions Database, 58
Akin, Charles Phillip, 5
Alderson, James, 7, 9
Aldrich, Kathy, 11
Allied Clinical Labs, 16-17
Ambulance services, see Medical Transportation
American Association of Retired Persons (AARP), 136 consumer surveys, xvi
American Hospital Association
battle over False Claims Act, 61-69, 96
American Medical Association, 94-96
Anderson, Thomas, 5
Arizona, managed care in Medicaid, 103
Artificial intelligence, 240-241
Audits,,177-179
claims audits,,179
cost report audits,,177-178
fraud audit protocols,,93-94, 157-158
medical review audit protocols 91-93,,157
of managed care organizations, 178-179
Medicare audits,,177-178
quality control audits,,146-147
random audits,,145-146,,224-225
see also Claims, edits and audits
Automated claims examination, experiment in,,169-170
Automated inquiry systems,,247-248
Automatic number identification,,248
Automatic Transaction Processing System, see Automated claimsexamination examine
Balanced Budget Act ( 1997),,58-59,,61
Basic American Medical, Inc.,,10
Bass Orthopedic,,2
Bauer, Robert,,9
Beneficiary Notification Program, see Explanation of Medical Benefits
Bielaus, Michael Paul,,24-25
Billing Specialists,,18-19
Blood Chemistry Panels,,14-17
Blue Cross/Blue Shield of Florida, 241-243
Blue Cross/Blue Shield plans,,74-76
Boston Globe,,25-26
Brumer, Michael,,23
Capitated systems as remedy for fee-for-service fraud, 52-55 see also Managed care
Castillo, Jesus N.,,20-21

-277-

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License to Steal: How Fraud Bleeds America's Health Care System
Table of contents

Table of contents

  • Title Page iii
  • Contents v
  • Preface vii
  • Introduction - Who Steals, and How? 1
  • Part One - The State of the Art 37
  • 1 - Control Failures 39
  • 2 - How Goes the War? 56
  • Part Two - New Frontiers for Control 81
  • 3 - False Claims 83
  • 4 - Managed Care 98
  • Part Three - The Nature of the Fraud-Control Challenge 115
  • 5 - The Pathology of Fraud Control 117
  • 6 - The Importance of Measurement 143
  • 7 - Assessment of Existing Fraud-Control Systems 162
  • 8 - The Antithesis of Modern Claims Processing 183
  • Part Four - Prescription for Progress 201
  • 9 - A Model Fraud-Control Strategy 203
  • 10 - Detection Systems 228
  • Conclusion 253
  • Acronyms and Abbreviations 257
  • Notes 259
  • Index 277
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