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The Investigative Medical Audit

The most powerful tool in the fight against Insurance Fraud

Favorably reviewed in the John Cooke Fraud Report, The Investigative Medical Audit manual is considered by those who have read it as the Bible on medical provider fraud and medical audit investigations.

The Medical Audit Investigations is comprised of three primary components, the clinic/provider investigation, the on-site facility inspection, and the review of medical records. Properly conducted, these three components can yield incredible results in combating suspect claims.

This text provides a detailed, in-depth, and comprehensive approach to what is unquestionably the most powerful tool in the fight against insurance fraud - the investigative medical audit.

Written by Eric Tackett
Published by the California Investigative Academy
150 pages; comb bound soft cover


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Table of Contents

Chapter One - The Most Powerful Tool in the Fight Against Fraud

  • Common Fraud Methods
  • When a Medical Audit be Considered
  • Reviewing the Demand Package
  • Indicators of Fraud
  • Before You Begin

Chapter Two - The Clinic Investigation

  • The Purpose of the Clinic Investigation
  • Establishing Clinic Ownership
  • Licensure Verification
  • On-Site Clinic Inspection
  • Copying the Medical File
  • Radiograpic Films
  • Completing the Clinic Inspection
  • Interviewing Clinic Personnel

Chapter Three - Who May Provide Physical Therapy and Who May Not

  • Medical Doctors
  • Physical Therapists
  • Physical Therapy Assistants
  • Physical Therapy Aides
  • Physician Assistants
  • Medical Assistants
  • Chiropractors and Chiropractic Assistants
  • Acupuncturists

Chapter Four - Reviewing the Medical File

  • Initial Review Procedures
  • Doctor's Narrative Report
  • Radiology Report
  • Handwritten Exam Notes
  • Doctor's Diagnosis
  • Treatment Plan
  • Physical Therapy Evaluation
  • Treatment Record
  • Progress Notes
  • Sign-In Sheets and Patient Registers
  • Patient/Accident Information Forms
  • Billing Statements

Chapter Five - Understanding CPT Codes

  • Current Procedural Terminology (CPT)
  • Catagories
  • Evaluation/Management
  • Key Components
  • Contributing Factors
  • Upcoding
  • Radiology
  • Unbundling
  • Physical Medicine/Modalities
  • Duplicative Therapy
  • Common Billing Codes

Chapter Six - Excerpts From the Healing Arts Statutes

  • Business & Professions Code
  • California Chiropractic Initiative Act
  • Medical Practice Act
  • Physical Therapy Practice Act
  • Nursing Act
  • Acupuncture Practice Act
  • Moscone-Knox Professional Corporations Act

Chapter Seven - Accepted Standards of Practice

  • California Code of Regulations
  • Mercy Conference Standards
  • Physical Therapy Guidelines

Chapter Eight - Physical Therapy Equpment & Modalities

  • Modalities, Procedures & Equipment
  • Common Medical Terms

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