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Please note, once you complete your purchase, Cheetah registration instructions and login credentials to access your 3-month online subscription will be emailed to you within one business day. Overview Table of Contents Volumes. Health Care Fraud and Abuse Compliance Manual An immensely practical resource, Health Care Fraud and Abuse Compliance Manual provides a comprehensive overview of legislative and regulatory restrictions that affect the way health care providers conduct business and how they structure relationships among themselves.
With Health Care Fraud and Abuse Compliance Manual : You'll receive coverage of all the critical laws and considerations, including: false claims and fraudulent billings, civil and criminal penalties, the antikickback statute, the safe harbor regulations, the Stark Law, and state statutes You'll get practical advice on developing a corporate compliance program that can help you stay on the right side of the law You'll learn about the structures, goals, and procedures of agencies that investigate health care fraud You'll get an in-depth understanding of what goes into a fraud and abuse investigation - and how you can respond to an investigation to best defend your organization And much, much more!
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PDF Commercial Fraud Manual
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The board also may delegate anti-fraud responsibilities to specific executives and managers, including those in charge of managing risks and controls. Roles and responsibilities should be clearly defined. While not all fraud can be avoided, an active board can foster an environment in which fraud is more likely to be prevented, deterred, and promptly detected.
A sound corporate culture should discourage imprudent risk-taking. Incentives or requirements for employees to meet sales goals, financial performance goals, and other business goals, particularly if such goals are aggressive, can result in heightened fraud risk. Processes should be designed to anticipate fraud and deploy a combination of preventive controls and detective controls.
Small business fraud and the trusted employee
Detective controls are important because even with strong governance and oversight, collusion or circumvention of internal controls can allow fraud to occur. Some practices and controls may be both preventive and detective in nature. Preventive controls are designed to deter fraud or minimize its likelihood. The following are some examples:. Detective controls are designed to identify and respond to fraud after it has occurred. Software and technology tools, developed internally or purchased from a third party, can assist with anti-fraud efforts.
Commercial Fraud Manual
Depending on the specific products and services offered, management might deploy solutions that serve to detect anomalies and prevent potential fraudulent transactions or activities. These solutions can monitor transactions and behaviors, employ layered or multifactor authentication, monitor networks for intrusions or malware, analyze transactions on internal bank platforms, and compare data with consortium or publicly available data.
Reporting should allow management and directors to measure performance. Practices can include benchmarking current fraud losses against loss history or industry data. Examples of metrics and analysis banks can use to measure and monitor fraud risk include the following:. Management should identify fraud losses as internal or external. Larger, more complex banks generally maintain this information in an operational loss database or similar system. Banks should have processes for internal investigations, law enforcement referrals, regulatory notifications, 10 and reporting.
A bank is required to file a SAR for known or suspected fraud meeting regulatory thresholds. Pursuant to section b , before exchanging information, the bank must register with the U. Current section b participants may share information with one another regarding individuals, entities, organizations, and countries for purposes of identifying and, when appropriate, reporting activities that may involve possible specified unlawful activities. FinCEN has issued guidance clarifying that, if section b participants suspect that transactions may involve the proceeds of specified unlawful activities, such as fraud, under the money laundering statutes, 12 information related to such transactions can be shared under the protection of the section b safe harbor.
Effective internal and external audit programs are a critical defense against fraud and provide vital information to the board of directors about the effectiveness of internal control systems.
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