The healthcare system in the United States is arguably the best in the world, but it is constantly vulnerable to waste, fraud, and abuse. This program will provide an overview of the current United States healthcare system; give estimated fraud costs; and list useful definitions for physicians. It will offer insight into how criminal investigations are initiated and assembled by law enforcement and prosecutorial agencies. It will also outline steps to protect a physician's practice from fraud schemes and review SAS No. 99 audit requirements when designing and implementing a fraud prevention strategy.

Use of Materials

Online
The user should begin by watching the streamed video segment, if any, or listening to the streamed audio segment, if any, for the chapter before reading the text. The user may wish to make notes of the most important concepts and any terms that are new. Next, the user should review the learning objectives at the beginning of the chapter and read the chapter. The user should work through each of the examples. After the user has studied each chapter, s/he should click on the link at the left to complete the interactive study questions. If the user answers a study question incorrectly, s/he should review the section of the text that is indicated at the end of the explanation to the study question to assure comprehension of the material. The user should review the learning objectives once more to consider achievement of the objectives. After the user has finished watching the streamed video, if any, or listening to the streamed audio, if any, and reading the text and working through the study questions, s/he may wish to review her/his notes and any sections of the text or video/audio, if any, that were difficult. When the user is ready, s/he should click on the link to the left to complete the quizzer. The user's CPE certificate will be provided immediately upon successful completion of the quizzer.

Software
The user should begin by reviewing the learning objectives at the beginning of the chapter and read the chapter. The user should work through each of the examples. As the user studies each chapter, s/he should complete the interactive study questions that appear in the lower panel of the screen. If the user answers a study question incorrectly, s/he should review the section of the text that is indicated at the end of the explanation to the study question to assure comprehension of the material. The user should review the learning objectives once more to consider achievement of the objectives. After the user has finished reading the text and working through the study questions, s/he may wish to review her/his notes and any sections of the text that were difficult. When the user is ready, s/he should click on the link at the far left to complete the quizzer. The user should email her/his quizzer statistics using the quizzer submission link in the software and the user's CPE certificate will be mailed to her/him.

Chapter 1 gives an introduction to fraud prevention for physicians.

Chapter 2 reviews government agencies involved in investigating healthcare fraud.

Chapter 3 describes the steps in an investigation.

Chapter 4 examines ways a physician can protect her/his practice.

Chapter 5 describes internal steps a practice can take to protect the practice.

Chapter 6 reviews the reliance and impact of SAS No. 99 and the COSO internal control framework.

Throughout this program, the user will find explanations and discussions regarding some of the issues that often face practitioners. In order to enhance the user's comprehension of the material and highlight important practical considerations, this publication includes the following designations:

A Biskpoint presents analysis or commentary that attempts to explain or clarify authoritative guidance.

A Bisktip provides practical advice that may be used to help improve client service or service to the practitioner‹s organization.

• Explain the overall response of the U.S. Government to the healthcare fraud problem

• Discuss the concepts of criminal intent; to act knowingly; to act willingly; to act with good faith; to act intentionally; and motive

• Discuss a common framework for fraud investigations

• Explain common steps taken by investigators once allegations of fraud are confirmed

• Provide some initial steps to consider when designing systems to protect physician practices

• Discuss how thieves use knowledge of business and accounting to perpetrate and conceal fraud schemes

• Discuss the interview process

• Discuss the importance of the Committee of Sponsoring Organizations of the Treadway Commission (COSO)

• Discuss the audit requirements of SAS No. 99