Process Group

Audit/Fraud Management

Objective

Manage identified cases of suspicious program benefit utilization to closure

Input

• List of suspected cases

• Inquiries

• Evidence

Output

• Corrective action (i.e., remove beneficiary, remove provider, file charges with court)

Measurable Outcomes

• List of verified fraudulent claims

• Plan of corrective actions

Sources

• Joint Learning Network, 2012

• File: NHIIS_Phase_1_Public_Report_JLN_IT_Workshop_FINAL_Jan182012_A4.pdf