decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Fraud and Abuse / Fraud and abuse investigations
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Article Overview
This premium article describes how carrier fraud and abuse units are organized, what responsibilities they perform, and how they coordinate investigations and referrals involving suspected program abuse. It is aimed at readers who need a high-level understanding of fraud detection, case development, and administrative response within the Medicare environment.
Why This Topic Matters
Understanding fraud and abuse investigation processes helps compliance, billing, audit, and integrity professionals recognize how carriers identify risk, gather facts, and route cases to the appropriate oversight channels.
What You Will Learn
- How carrier fraud and abuse units are structured
- The general responsibilities of fraud detection and prevention teams
- How allegations and leads are gathered from multiple sources
- How suspected cases may be handled through administrative action and referral pathways
Who Should Read This
- Medical coders
- Compliance professionals
- Billing staff
- Audit professionals
- Healthcare administrators
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