Fraud Management System
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Path:
Provider Compliance - Submission of Accurate Claims and Information > Billing - Patient not present > Billing for services not provided - Using phantom or deceased persons' names > Patient File Does Not Agree with Billing Records > Perform review of selected patient files
Finding
:
Finding Type:
Compliance Red Flag
Compliance Violation
Concealment Control
Concealment Red Flag
Errors & Omissions
Fraud
Fraud Suspect
Non-segregated Duties
Policy Red Flag
Policy Violation
Procedural Violation
Procedure Red Flag
Scenario Control
Scenario Red Flag
Undetermined
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Reported to:
Date Reported:
Detail:
detail finding statement
Risk Rating:
Extremely High
High
Moderate
Low
Risk:
some residual risk
Management Risk Response:
Management response goes here
Target Date:
Status:
Final Report
Under Review
Verbal
Waive
Written Finding
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