Organizations that fail to identify and eliminate fraud are losing hundreds of thousands of dollarsand many dont even know it! Many claims professionals dont have the time or resources to spot the red flags that indicate a fraudulent workers compensation claim, and even if they stumble upon one by chance, they fail to conduct a comprehensive investigation. Mario S. Pecoraro, CEO of Alliance Worldwide Investigative Group, provides proactive strategies that will save you resources, money, and time investigating claims. The twenty best practices he explores will help you: hire the type of employee who wont file a claim in the first place; engage in preventative maintenance throughout the life of a claim; determine who should conduct an investigation when a claim is filed; carry out the investigative process using a variety of tools. Filled with case studies demonstrating where investigations went wrong (and where they went right), youll be equipped to apply best practices and avoid common mistakes. Start saving money, and get the right team in place with The Claim Game.

The book is designed as a primer for claims investigators, health care managers, QA/QI personnel, in-house counsel, paralegals, personal injury attorneys, and others whose duties include the investigation of actual and potential medical malpractice lawsuits. It can be used as a desktop reference, self-study guide, or as part of a formal orientation program for risk managers and quality assurance personnel. The book contains a step-by-step description of the claims investigation. It also provides instruction on reviewing medical records; identifying adverse patient occurrences; selecting, locating and interviewing personnel involved in occurrences; analyzing investigative findings; and writing the investigation report.

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 suspectsTips on investigative case planning, goals, and strategiesSample visual aids for use when briefing others about your investigative findingsGuidance on presenting information obtained from healthcare investigations and on how to testify in courtTechniques for uncovering previously undetected fraudThe 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 o