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Healthcare Fraud

Autor: Rebecca S. Busch
Publisher: John Wiley & Sons
ISBN: 9780470227084
File Size: 17,92 MB
Format: PDF, Kindle
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According to private and public estimates, approximately $24 million is lost per hour to healthcare waste, fraud, and abuse. A must-have reference for auditors, fraud investigators, and healthcare managers, Healthcare Fraud: Auditing and Detection Guide provides tips and techniques to help you spot—and prevent—the "red flags" of fraudulent activity within your organization. Eminently readable, it is your “go-to” resource, equipping you with the necessary skills to look for and deal with potential fraudulent situations.

Healthcare Fraud

Autor: Rebecca S. Busch
Publisher: John Wiley & Sons
ISBN: 1118179803
File Size: 10,63 MB
Format: PDF, Mobi
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"This second edition provides comprehensive guidance on auditing and fraud detection for healthcare providers and company healthcare plans. New chapters have been added covering a comprehensive auditing model developed by the author on all of the key elements that must be addressed: Primary Healthcare, Secondary Healthcare, Information/Data Management and Privacy, Damages/Risk Management, and transparency. In addition to six new chapters, the current edition material will all be updated and brought up to date"--Provided by publisher.

Healthcare Fraud Investigation Guidebook

Autor: Charles E. Piper
Publisher: CRC Press
ISBN: 1498752616
File Size: 9,16 MB
Format: PDF, Kindle
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Some have estimated that healthcare fraud in the United States results in losses of approximately $80 billion a year. Although there are many books available that describe how to "detect" healthcare fraud, few address what must be done after the fraud is detected. Filling this need, Charles Piper’s Healthcare Fraud Investigation Guidebook details not only how to detect healthcare fraud, but also how to "investigate" and prove the wrongdoing to increase the likelihood of successful prosecution in court. The book starts by covering the history of healthcare insurance and the various types of fraud schemes. It presents Charles Piper’s unique approach to investigating (The Piper Method) which allows readers to conduct as many as 10 simultaneous investigations for each case. It emphasizes the importance of simultaneously searching for waste and abuse as well as systemic weaknesses and deficiencies that caused or contributed to the problem or wrongdoing under investigation and then make recommendations for improvement. It also provides: Questions to ask whistleblowers, complainants, employers, employees, and healthcare providers who are suspects Tips on investigative case planning, goals, and strategies Sample visual aids for use when briefing others about your investigative findings Guidance on presenting information obtained from healthcare investigations and on how to testify in court Techniques for uncovering previously undetected fraud The book includes a sample case study that walks readers through a mock case—from the time the case is received through the end. The case study demonstrates how to initiate, plan, and conduct a thorough and complete healthcare fraud investigation while incorporating Piper’s proven methodology. Sharing insights gained through Charles Piper’s decades of experience as a federal special agent and certified fraud examiner, the Healthcare Fraud Investigation Guidebook aims to revolutionize the way that healthcare fraud investigations are conducted. It provides the understanding you need to not only put a bandage on the problem of healthcare fraud, but to actually start curing the greed that is poisoning the healthcare industry.

Insurance Fraud Casebook

Autor: Laura Hymes
Publisher: John Wiley & Sons
ISBN: 1118700872
File Size: 9,60 MB
Format: PDF
Read: 1945
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Real case studies on insurance fraud written by real fraud examiners Insurance Fraud Casebook is a one-of-a-kind collection consisting of actual cases written by fraud examiners out in the field. These cases were hand selected from hundreds of submissions and together form a comprehensive picture of the many types of insurance fraud—how they are investigated, across industries and throughout the world. Entertaining and enlightening, the cases cover every type of insurance fraud, from medical fraud to counterfeiting. Each case outlines how the fraud was engineered, how it was investigated, and how perpetrators were brought to justice Written for fraud examiners, auditors, and insurance auditors Other titles by Wells: Fraud Fighter and Corporate Fraud Handbook, Third Edition Edited by Dr. Joseph T. Wells, the founder and Chairman of the Association of Certified Fraud Examiners (ACFE), the world's leading anti-fraud organization, this book reveals the dangers of insurance fraud and the measures that can be taken to prevent it from happening in the first place.

License To Steal

Autor: Malcolm K Sparrow
Publisher: Basic Books
ISBN: 0465010741
File Size: 15,56 MB
Format: PDF, ePub
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Who steals? An extraordinary range of folk--from low-life hoods who sign on as Medicare or Medicaid providers equipped with nothing more than beepers and mailboxes, to drug trafficking organizations, organized crime syndicates, and even major hospital chains. In License to Steal, Malcolm K. Sparrow shows how the industry's defenses, which focus mostly on finding and correcting billing errors, are no match for such well orchestrated attacks. The maxim for thieves simply becomes "bill your lies correctly." Provided they do that, fraud perpetrators with any degree of sophistication can steal millions of dollars with impunity, testing payment systems carefully, and then spreading fraudulent billings widely enough across patient and provider accounts to escape detection. The kinds of highly automated, quality controlled claims processing systems that pervade the industry present fraud perpetrators with their favorite kind of target: rich, fast paying, transparent, utterly predictable check printing systems, with little threat of human intervention, and with the U.S. Treasury on the end of the electronic line. Sparrow picks apart the industry's response to the government's efforts to control this problem. The provider associations (well heeled and politically influential) have vociferously opposed almost every recent enforcement initiative, creating the unfortunate public impression that the entire health care industry is against effective fraud control. A significant segment of the industry, it seems, regards fraud and abuse not as a problem, but as a lucrative enterprise worth defending. Meanwhile, it remains a perfectly commonplace experience for patients or their relatives to examine a medical bill and discover that half of it never happened, or that; likewise, if patients then complain, they discover that no one seems to care, or that no one has the resources to do anything about it.Sparrow's research suggests that the growth of capitated managed care systems does not solve the problem, as many in the industry had assumed, but merely changes its form. The managed care environment produces scams involving underutilization, and the withholding of medical care schemes that are harder to uncover and investigate, and much more dangerous to human health. Having worked extensively with federal and state officials since the appearance of his first book on this subject, Sparrow is in a unique position to evaluate recent law enforcement initiatives. He admits the "war on fraud" is at least now engaged, but it is far from won.

Fraud Analytics Using Descriptive Predictive And Social Network Techniques

Autor: Bart Baesens
Publisher: John Wiley & Sons
ISBN: 1119133122
File Size: 15,57 MB
Format: PDF, Kindle
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Detect fraud earlier to mitigate loss and prevent cascading damage Fraud Analytics Using Descriptive, Predictive, and Social Network Techniques is an authoritative guidebook for setting up a comprehensive fraud detection analytics solution. Early detection is a key factor in mitigating fraud damage, but it involves more specialized techniques than detecting fraud at the more advanced stages. This invaluable guide details both the theory and technical aspects of these techniques, and provides expert insight into streamlining implementation. Coverage includes data gathering, preprocessing, model building, and post–implementation, with comprehensive guidance on various learning techniques and the data types utilized by each. These techniques are effective for fraud detection across industry boundaries, including applications in insurance fraud, credit card fraud, anti–money laundering, healthcare fraud, telecommunications fraud, click fraud, tax evasion, and more, giving you a highly practical framework for fraud prevention. It is estimated that a typical organization loses about 5% of its revenue to fraud every year. More effective fraud detection is possible, and this book describes the various analytical techniques your organization must implement to put a stop to the revenue leak. Examine fraud patterns in historical data Utilize labeled, unlabeled, and networked data Detect fraud before the damage cascades Reduce losses, increase recovery, and tighten security The longer fraud is allowed to go on, the more harm it causes. It expands exponentially, sending ripples of damage throughout the organization, and becomes more and more complex to track, stop, and reverse. Fraud prevention relies on early and effective fraud detection, enabled by the techniques discussed here. Fraud Analytics Using Descriptive, Predictive, and Social Network Techniques helps you stop fraud in its tracks, and eliminate the opportunities for future occurrence.

Statistics And Health Care Fraud

Autor: Tahir Ekin
Publisher: CRC Press
ISBN: 1315278243
File Size: 10,56 MB
Format: PDF
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Statistics and Health Care Fraud: How to Save Billions helps the public to become more informed citizens through discussions of real world health care examples and fraud assessment applications. The author presents statistical and analytical methods used in health care fraud audits without requiring any mathematical background. The public suffers from health care overpayments either directly as patients or indirectly as taxpayers, and fraud analytics provides ways to handle the large size and complexity of these claims. The book starts with a brief overview of global healthcare systems such as U.S. Medicare. This is followed by a discussion of medical overpayments and assessment initiatives using a variety of real world examples. The book covers subjects as: • Description and visualization of medical claims data • Prediction of fraudulent transactions • Detection of excessive billings • Revealing new fraud patterns • Challenges and opportunities with health care fraud analytics Dr. Tahir Ekin is the Brandon Dee Roberts Associate Professor of Quantitative Methods in McCoy College of Business, Texas State University. His previous work experience includes a working as a statistician on health care fraud detection. His scholarly work on health care fraud has been published in a variety of academic journals including International Statistical Review, The American Statistician, and Applied Stochastic Models in Business and Industry. He is a recipient of the Texas State University 2018 Presidential Distinction Award in Scholar Activities and the ASA/NISS y-Bis 2016 Best Paper Awards. He has developed and taught courses in the areas of business statistics, optimization, data mining and analytics. Dr. Ekin also serves as Vice President of the International Society for Business and Industrial Statistics.

Legal Nurse Consulting Principles And Practices

Autor: Julie Dickinson
Publisher: CRC Press
ISBN: 1000458598
File Size: 20,29 MB
Format: PDF, Docs
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Legal Nurse Consulting Principles and Practices, Fourth Edition, provides foundational knowledge on the specialty nursing practice of legal nurse consulting. Legal nurse consulting is defined, and essential information about the practice is discussed (history, certification, scope and standards of practice, and ethical and liability considerations). The essentials of the law and medical records are explored. Analysis of the various types of legal cases on which legal nurse consultants work is provided, as are other practice areas for legal nurse consultants. The various roles and skills of legal nurse consultants are explored, and the textbook concludes with discussion of the ways in which legal cases are adjudicated. This volume allows nurses to bridge the gap from their clinical experience to the unfamiliar territory of the legal world, with practical advice on topics including tactics for being cross-examined in the courtroom and investigative and analytical techniques for medical records. Individual chapters by subject-matter experts focus on the full range of legal, medical, and business issues that new or experienced legal nurse consultants and nurse experts will encounter in their work. A nuanced look at the realities and complexities of toxic torts, medical malpractice cases, civil rights in correctional healthcare, ERISA and HMO litigation, and other practice areas is offered. Suitable for experienced nurses studying for certification as legal nurse consultants, and for expert witnesses, practitioners seeking to expand their current legal nurse roles, and other healthcare and legal practitioners.

The Cyber Patient

Autor: Rebecca Mendoza Saltiel Busch
Publisher: CRC Press
ISBN: 0429953720
File Size: 16,60 MB
Format: PDF, Kindle
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With the use of electronic health records (EHR) transforming the healthcare industry, the use of information technology in the maintenance of personal health records poses a range of issues and opportunities for every medical organization, The Cyber Patient expertly walks readers through the elements required for an efficient, well-run healthcare record management system, while reflecting the U.S. government’s goal of achieving widespread adoption of interoperable electronic health records to improve the quality and efficiency of healthcare while maintaining the levels of security and privacy that consumers expect. The author also provides an update as to where the industry stands in their push of interoperability and the increased use of data as an analytic tools. Providing an application readers can adopt as a model, this important book examines the infrastructure of electronic health records and how government criteria have impacted and will continue to impact both private and public marketplaces. This valuable resource also addresses how auditors, controllers, and healthcare providers can keep up with the market’s continued move towards an interoperable e-health world, without neglecting clinical and financial accountability in the delivery of healthcare. As e-health continues to develop and transform, The Cyber Patient thoughtfully prepares professionals to plan and implement an effective EHR as wel as internal controls system within any clinical setting.

The Complete Guide To Spotting Accounting Fraud Cover Ups

Autor: Martha Maeda
Publisher: Atlantic Publishing Company
ISBN: 160138212X
File Size: 27,15 MB
Format: PDF, Mobi
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In 2009, high-profile fraud cases like the Ponzi schemes of Bernard Madoff and Arthur Nadel vividly illustrated the harm done to investors who placed their trust in these apparently successful money managers and then discovered their money had never been invested at all. News stories featured 90-year-olds forced by necessity to work in supermarkets, elderly people losing their homes because their life savings were gone, and wealthy retirees suddenly unable to pay their electricity bills. Charities were forced to curtail their services, lay off staff, and even close their doors forever as their funds evaporated. Almost every day, there are stories in the media about dishonest employees who have robbed their organisations of hundreds of thousands of dollars. Not so well-publicised are the countless smaller thefts occurring every day from cash registers, warehouses, and business bank accounts. Sadly, the organisations that have the most to lose small businesses, family-run companies, churches, and charities are often the most vulnerable because of their size and inexperience. According to the Association of Certified Fraud Examiners, accounting fraud cost over $994 billion in 2008, and the average organisation lost 7 percent of its total revenue to fraud. How can you prevent this from happening to you as an investor, business owner, or a person attempting to acquire or merge with another firm? Read this book and you will be able to understand, detect, and avoid accounting fraud. You will learn how to identify fraud, how to spot minor abnormalities that may hide fraud, how to spot forgeries, and how to prove your case, as well as what to immediately suspect and methods for uncovering scams. You will know what signs to look for, including excessive turnover of lawyers and auditors, changing professionals in the middle of a transaction, inconsistent information, and significant declines in stock prices. In addition, you will know how to recognise the common manoeuvres, earnings manipulation, premature and fictitious revenue, overvalued assets, undervalued liabilities, bogus revenue, expenses that have been shifted to another period, overstating revenues, understating expenses, and the misuse and misdirecting of funds. This new book is filled with studies and discussions of fraud cases and how they could have been avoided, checklists for detecting accounts misdeeds, and advice from analysts, CFOs, and CPAs. This manual will be an indispensable aid for serious investors, industry pros, acquisition and merger managers, and small business owners alike. After reading this book you will no longer have to worry about accounting fraud and you can increase your company's profits.

Forensic Analytics

Autor: Mark J. Nigrini
Publisher: John Wiley & Sons
ISBN: 9781118087633
File Size: 11,34 MB
Format: PDF, ePub, Docs
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Discover how to detect fraud, biases, or errors in your data using Access or Excel With over 300 images, Forensic Analytics reviews and shows how twenty substantive and rigorous tests can be used to detect fraud, errors, estimates, or biases in your data. For each test, the original data is shown with the steps needed to get to the final result. The tests range from high-level data overviews to assess the reasonableness of data, to highly focused tests that give small samples of highly suspicious transactions. These tests are relevant to your organization, whether small or large, for profit, nonprofit, or government-related. Demonstrates how to use Access, Excel, and PowerPoint in a forensic setting Explores use of statistical techniques such as Benford's Law, descriptive statistics, correlation, and time-series analysis to detect fraud and errors Discusses the detection of financial statement fraud using various statistical approaches Explains how to score locations, agents, customers, or employees for fraud risk Shows you how to become the data analytics expert in your organization Forensic Analytics shows how you can use Microsoft Access and Excel as your primary data interrogation tools to find exceptional, irregular, and anomalous records.

Leveraging Data In Healthcare

Autor: Rebecca Mendoza Saltiel Busch
Publisher: CRC Press
ISBN: 1498757731
File Size: 16,88 MB
Format: PDF, Mobi
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The healthcare industry is in a state of accelerated transition. The proliferation of data and its assimilation, access, use, and security are ever-increasing challenges. Finding ways to operationalize business and clinical data management in the face of government and market mandates is enough to keep most chief officers up at night! Leveraging Data in Healthcare: Best Practices for Controlling, Analyzing, and Using Data argues that the key to survival for any healthcare organization in today’s data-saturated market is to fundamentally redefine the roles of chief information executives—CIOs, CFOs, CMIOs, CTOs, CNIOs, CTOs and CDOs—from suppliers of data to drivers of data intelligence. This book presents best practices for controlling, analyzing, and using data. The elements of preparing an actionable data strategy are exemplified on subjects such as revenue integrity, revenue management, and patient engagement. Further, the book illustrates how to operationalize the electronic integration of health and financial data within patient financial services, information management services, and patient engagement activities. An integrated environment will activate a data-driven intelligent decision support infrastructure. The increasing impact of consumer engagement will continue to affect the organization’s bottom line. Success in this new world will need collaboration among the chiefs, users, and data creators.

Financial Statement Fraud

Autor: Gerard M. Zack
Publisher: John Wiley & Sons
ISBN: 1118301552
File Size: 6,38 MB
Format: PDF, Docs
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FINANCIAL STATEMENT FRAUD Strategies for Detection and Investigation Although financial statement fraud is the least frequently encountered fraud, it is by far the most costly, at a median loss of $1 million per case. Yet, the indirect losses from financial statement fraud—jobs, support, morale, and loyalty—are also significant and almost impossible to measure. Learn how to spot the warning signs before the damage is done. Financial Statement Fraud explores the many different methods of perpetrating financial statement fraud, the accounting principles that are exploited, and the methods to detect and prevent fraud in any organization. Assuming an understanding of basic financial statements and the purpose each serves, as well as basic accounting concepts, author Gerard Zack highlights the many different types of fraud schemes. Financial Statement Fraud provides auditors, fraud investigators, government agencies, and investment analysts with detailed descriptions of the most common or emerging schemes involving the preparation and issuance of fraudulent financial statements. Filling the need for practical guidance on financial statement fraud and the roles and responsibilities within companies, Financial Statement Fraud features: References to pertinent U.S. and international accounting standards violated in the preparation of fraudulent financial statements A wide range of detection tools, from the simplest of ratios to complex analyses and tests, as well as fraud indicators A comprehensive, global approach that includes U.S. GAAP and IFRS Red flags and ratios to help you detect financial statement fraud schemes Coverage of auditor liability: when is an auditor liable for failing to detect fraud? Real-world cases that illustrate many of the fraud schemes featured throughout the book A companion website includes copies of SEC Accounting and Auditing Enforcement Releases (AAERs), complaints that were filed, and various other documents associated with most of the cases cited in the book. These documents provide all of the details associated with each case, enabling researchers to perform their own analysis to more fully understand the schemes and relate them to the detection tips provided in the book. Financial statement fraud can cost an organization more than just revenue. Arm yourself with the knowledge to identify where it happens, when to expect it, and how to detect it with the expert guidance found in Financial Statement Fraud.

Electronic Health Records

Autor: Rebecca S. Busch
Publisher: John Wiley & Sons
ISBN: 0470399465
File Size: 22,88 MB
Format: PDF, Mobi
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Electronic Health Records: An Audit and Internal Control Guide describes the infrastructure of electronic health records and the impact that the government's new criteria will have on the private and public marketplace. Understand what to look for in a health care record management system and find tips and helpful guidance for implementation. If you are trying to facilitate an audit of a health record management system, you can apply the example described in the model, which will serve as a timely model and invaluable resource.

Fraud 101

Autor: Stephen Pedneault
Publisher: John Wiley & Sons
ISBN: 9780470647844
File Size: 19,45 MB
Format: PDF, Docs
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A straightforward guide explaining the nature of financial fraud Fraud continues to be one of the fastest growing and most costly crimes in the United States and around the world. The more an organization can learn about fraud in general and the potential fraud risks that threaten the financial stability of the organization's cash flow, the better that organization will be equipped to design and implement measures to prevent schemes from occurring in the first place. Fraud 101, Third Edition serves as an enlightening tool for you, whether you are a business owner or manager, an accountant, auditor or college student who needs to learn about the nature of fraud. In this invaluable guide, you will discover and better understand the inner workings of numerous financial schemes and internal controls to increase your awareness and possibly prevent fraud from destroying your organization's financial stability. It offers guidance, understanding, and new, real-world case studies on the major types of fraud, including An understanding of why fraud is committed An overview of financial fraud schemes White-collar crime Uncovering employee embezzlements Establishing internal fraud controls The nature of collecting evidence With case studies included throughout the book to gain insight to the real world of fraud, Fraud 101, Third Edition describes the features of fraud and then provides proven methods of prevention, as well as solutions to expose different types of fraud.

Health Care Fraud

Autor: Williamd Edward Ackerman, III
Publisher: Createspace Independent Publishing Platform
ISBN: 9781976463044
File Size: 29,91 MB
Format: PDF, Docs
Read: 3991
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The medical profession and health care in general has deteriorated over the past twenty years. It has become plagued with fraudulent behaviors. It is difficult for individuals to know if they are being scammed. Fraud unfortunately exists in all aspects of health care today. In 2011, $2.27 trillion was spent on health care and more than four billion health insurance claims were processed in the United States. It is an undisputed reality that some of these health insurance claims are fraudulent. No institution has undone more quickly and more completely than American medicine. In only a few decades, the medical system has been overrun by organizations seeking to exploit for profit the trust that susceptible and sick Americans place in their healthcare. No doctor wants to be identified as being out of step with medical practice norms. Furthermore, most health care providers do not want a decrease in profit margins as well. This book is about the millions of Americans who have access to what some would call the best medical care in the world but are being swindled. Of course, there are millions of uninsured Americans whose access to care is heartlessly limited. The problems of fraudulent health care described in this book are less likely to transpire to the latter group, simply because they receive less medical care. This book is about the relentless expansion of medicine and our health providers increasing tendency to only make a diagnosis so that further treatments can be done to increase their revenues. Americans have been taught to be concerned about their health. We are all aware that types of hidden jeopardies prowl inside of us. The conventional wisdom is that it's always better to know about these dangers so that something can be done. That's why we are so enthusiastic about amazing medical technologies that can detect abnormalities even when we reason we are well. That's also why we welcome the identification of risk factors, disease awareness campaigns, cancer screening, genetic testing etc. Americans love a diagnosis so that they can receive attention and health care whether or not it helps them. But it's also true that we do receive too much of it in some circumstances. Some people are diagnosed and treated needlessly by swindlers who do unnecessary or dangerous treatments to increase their profit which is one reason why this book was written. Our legislators have proven themselves either unwilling or incapable of reining in the increasingly outrageous costs faced by patients, and market-based solutions only seem to funnel larger and larger sums of our money into the hands of corporations. Impossibly high insurance premiums and inexplicably large bills have become facts of life. The majority of health care frauds are committed by a very small minority of dishonest health care providers. Unfortunately, the stock in trade of fraud-doers is to take advantage of the confidence that has been entrusted to them in order to commit ongoing fraud on a very broad scale. Another reason for this book is to inform individuals that rewards can be made by reporting health care fraud by becoming a whistle blower. Health care consumers need to identify these health care fraudsters and report them to ultimately attempt to salvage what remains of our health care structure. Fighting Medicare fraud is an important part of safeguarding our healthcare for future generations. Health deception costs Americans billions of dollars. We all must do our parts to reverse this trend. If you suspect that something has happened illegally with respect to medical care, then it is your duty to blow the whistle. Doing so makes you part of the solution. This book addresses the types of fraud which plague the healthcare industry and describes the most common fraudulent behavior throughout this industry and how to report fraud and possibly receive a reward. We must all do our part in trying to save our health care system!

Insurance Fraud Casebook

Autor: Laura Hymes
Publisher: John Wiley & Sons
ISBN: 1118700872
File Size: 13,10 MB
Format: PDF
Read: 7649
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Real case studies on insurance fraud written by real fraud examiners Insurance Fraud Casebook is a one-of-a-kind collection consisting of actual cases written by fraud examiners out in the field. These cases were hand selected from hundreds of submissions and together form a comprehensive picture of the many types of insurance fraud—how they are investigated, across industries and throughout the world. Entertaining and enlightening, the cases cover every type of insurance fraud, from medical fraud to counterfeiting. Each case outlines how the fraud was engineered, how it was investigated, and how perpetrators were brought to justice Written for fraud examiners, auditors, and insurance auditors Other titles by Wells: Fraud Fighter and Corporate Fraud Handbook, Third Edition Edited by Dr. Joseph T. Wells, the founder and Chairman of the Association of Certified Fraud Examiners (ACFE), the world's leading anti-fraud organization, this book reveals the dangers of insurance fraud and the measures that can be taken to prevent it from happening in the first place.