When most people hear the word fraud in healthcare, they probably picture something fairly obvious. A provider bills for a service they never performed. Someone submits a claim for a patient they never treated. An organization knowingly receives money for something it never provided. Those situations certainly happen. Healthcare fraud can involve intentional misrepresentation of services, medical necessity, billing, or other information in exchange for financial gain.

One of the challenges compliance professionals face is that the circumstances surrounding a potential fraud issue are not always straightforward. During COVID-19, for example, healthcare providers were working under extraordinary conditions, treating large numbers of patients while adapting to constantly changing requirements and operational realities.

This White Paper suggests enrollment information, ownership records, physician orders, proof of delivery, medical necessity documentation, beneficiary information, and billing patterns are likely to receive increasing attention.

Federal agencies are investing heavily in real-time analytics and cross-agency data sharing. Compliance programs that rely exclusively on retrospective audits and documentation reviews risk missing the very patterns regulators are now designed to detect.