How is  health care fraud investigation and audits conducted?

Expert Answers
mizzwillie eNotes educator| Certified Educator

Health care fraud and the audits which go with them are usually conducted with a multi-agency approach.  The investigators are literally following the money to help them ascertain the amount of fraud or culpability of the people involved.  The advent of electronic records allows the agencies charged with oversight of health care to track the money trail more easily knowing that there are many ways to hide the records.  As almost any audit does, the expenses claimed and the treatments given all have to match the reports the auditors check.  Then, once the extent of the fraud is known or at least the beginning of the extent, the investigators look at both people and records.  Does any one physician  or nurse consistently claim large amounts of time with individual patients?  Do the records kept back up their claims?  Does the amount of time seem realistic with each patient?  Does the money trail lead to other places as money laundering is always a possibility.  The monitoring of suspicious health care providers needs to be systematic and often system wide.  If the charges cover large amounts of money or a systematic defrauding of the government, then the state or government attorneys are brought  in to consider which charges can be proved.  The whole process takes time and money, so the fraud cases considered for prosecution are those with larger amounts of money involved or a record of systematic cheating of the government.