decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Fraud and Abuse / Potential sources of cases
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Article Overview
This short article explains the broad categories of sources that can lead to fraud and abuse cases in healthcare compliance and program integrity work. It is relevant to compliance staff, auditors, investigators, and revenue integrity teams who need to understand the types of referrals, complaints, reviews, and interagency inputs that may prompt case development. The article focuses on source categories and related program integrity context rather than coding rules or clinical coding guidance.
Why This Topic Matters
Understanding potential case sources helps organizations recognize how fraud and abuse concerns enter the investigative process and where internal or external referrals may arise. This supports compliance monitoring, audit planning, and coordination with oversight entities.
What You Will Learn
- Common categories of fraud and abuse case sources
- How complaints, referrals, and review processes contribute to case development
- Which healthcare oversight entities and agencies may generate leads
- The role of internal controls and audits in identifying potential cases
Who Should Read This
- Compliance professionals
- Medical auditors
- Program integrity staff
- Healthcare investigators
- Revenue integrity teams
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