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Chapter

Chapter
Fraud
DOI link for Fraud
Fraud book
Fraud
DOI link for Fraud
Fraud book
ABSTRACT
Fraud is defined as an intentional deception resulting in injury to another. Assessment of fraud within a health plan is complex. This chapter will focus on distinguishing normal behavior patterns from those potentially fraudulent and which should trigger a more thorough review. Materials and data appropriate for such a review are discussed and applied to various scenarios. Appropriate guidelines for drawing conclusions from the information and materials reviewed are presented. After a review of this chapter, the legal nurse consultant will have a fundamental guide and standardized approach for the evaluation of cases involving potential fraud or abuse within a government or private sponsored healthcare benefit plan.