Date of Award
Master of Science (MS)
This qualitative study examines the role of healthcare insurance investigators related to medical fraud among physicians billing for services not rendered. Grounded in academic scholarship, industry case studies and first-hand knowledge, this study introduces methods identifying fraudulent activities, fraud detection practices and implications from discovering fraud among physicians, patients, and health insurance companies. The three types of methodologies employed provide a lens into determining misappropriation of healthcare insurance and patient monetary funds.
Healthcare fraud falls within the arena of white-collar crime. It consists of filing dishonest healthcare claims to receive a profit. Fraudulent healthcare schemes come in many forms. The public is not aware of white collar crimes committed by medical professionals, and is not well informed of what security measures organizations exercise to prevent these occurrences from happening, (Price & Norris, 2009). This paper will focus on physicians’ fraudulent billing schemes for services not rendered and the process a private healthcare insurance company undergoes to investigate healthcare fraud. The paper discusses fraud detection, interviews and referrals to law enforcement. Each method will introduce a different phase within the investigation process.
Forte, Glenn Jr, "Investigating Physicians Billing for Services Not Rendered: Fraud Detection, Interviewing and Referral to Law Enforcement" (2018). Economic Crime Forensics Capstones. 31.