Healthcare Insurance Fraud Training Workshop

February 25-26, 2018, Hotel Towers Rotana, Dubai, UAE.

Training Objectives

  • Introduction to fraud principles and Healthcare/Insurance fraud.
  • Identify, describe, and assess healthcare/insurance fraud scenarios in all settings (provider, employer, patient, payer, government).
  • Develop and implement programs to identify healthcare/insurance fraud in all settings, and best practices to combat Healthcare/Insurance fraud.
  • Learn investigative techniques to identify Healthcare/Insurance fraud.
  • Develop writing skills in identifying and reporting Healthcare/Insurance fraud.
  • Latest global trends & challenges in healthcare/insurance fraud system
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Trainer(s) of this Training

Rebecca S. Bucsh

RN, MBA, CCM, CFE, CPC, CHS-111, CRMA, CICA, FIALCP, FHFMA
CEO, Medical Business Associates, Inc.

Book Author of “Healthcare Fraud: Auditing & Detection Guide”
Faculty member of the Association of Certified Fraud Examiners
 

More Detail

When Willie Sutton, an infamous twentieth-century bank robber, was asked why he robbed banks, he replied, “Because that’s where the money is.’’ The healthcare industry, too, has lots of money – estimated to be a $2.9 trillion industry in 2015. How many of these annual healthcare/insurance dollars are attributed to fraud? About $25 million per hour is stolen in healthcare in the United States alone. So, it’s a mounting problem and the impact is only going to grow.

This course will provide the investigative professionals with thorough knowledge of medical and healthcare/insurance fraud in both the private and government sectors particularly in context with the Middle East region. The participants will learn scams committed by claimants and providers, the effects of this type of fraud, red flags for fraud recognition, and investigative tips.

This course is designed to introduce the healthcare/insurance industry: a highly segmented market with high-dollar cash transactions, from a fraud, audit, and detection perspective. This course also teaches “what is normal” in the marketplace so that abnormalities become apparent. Healthcare/insurance fraud prevention, detection, and investigation methods are outlined, as are different types of healthcare schemes, red flags to spot these schemes, and how Healthcare/Insurance fraud is ultimately stopped.

The ultimate goal is to encourage participates to see beyond the eclipse created by healthcare/insurance fraud and sharpen audit and investigation skills to identify incontrovertible truth.
 

Completion of this course will provide attendees with an all-inclusive understanding of the scope of healthcare insurance fraud, ranging from the simplest situations to complex and sophisticated healthcare/insurance fraud crimes.
By the end of course, specifically, the attendees will have the know-how to:

  • Nature and types of healthcare/insurance frauds.
  • Healthcare/Insurance fraud: Implications for prevention, detection, and investigation.
  • Healthcare/Insurance fraud in International markets.
  • Knowing market players within the healthcare continuum in context with healthcare insurances.
  • How to recognize & avoid healthcare/insurance fraud.
  • Role of ethics in healthcare/insurance fraud prevention.
  • Components of the data mapping and data mining process.
  • Health Insurance Portability and Accountability Act (HIPAA) of 1996.
  • Audit guidelines in using PHI.
  • Healthcare/Insurance Fraud: Penalties & Consequences.
  • Normal infrastructure and anomaly tracking systems.
  • Data analysis models and clinical content data analysis.
  • Data-driven Health decisions in an e – Health environment.
  • Analytic tools and audit check lists.
  • Electronic Health Records and health offering vulnerabilities.
     

All levels of auditors, investigators and prosecutors working in the healthcare/insurance fraud area

  • Executive Management of insurance or reinsurance companies and hospitals
  • Certified Fraud Examiners (CFE)
  • Certified Information Systems Auditors (CISA)
  • Insurance Claims Adjudicators
  • Special Investigator Unit Directors/Auditors
  • Medical Claims Auditors
  • Third Party Administrators
  • Professionals looking to expand their knowledge of insurance fraud detection and prevention
  • Healthcare Insurance Companies
  • Healthcare Reinsurance Companies
  • Insurance/Healthcare Insurance Councils/Associations/Authorities
  • Healthcare Insurance brokerages
  • Healthcare Ministries , Authorities and Medical Cities
  • Hospitals
  • Medical Centers
     
  • Presentations & Lectures
  • Group Discussions
  • Exercises & use cases
  • Certificate of Achievement
  • Course material & Handouts
  • USB device with all material
  • Study binder
  • International buffet Lunch with coffee/tea breaks
     

Hotel Towers Rotana
Dubai, United Arab Emirates
P.O. Box 30430 Dubai U.A.E
00 971 (0) 4 3122130
View Map

Course Fee $2,095/Participant

Individual
Book & pay on or before Jan. 25th, 2018 & get
10% addtional discount USD 1,885/participant
Corporate (Group Discount)
10% Discount on minimum of 3 Participants
 


Healthcare Insurance Fraud - Course Schedule

Day 1 - Sunday 25 February, 2018
Opening Session

Registration and Intro

Session One

I. Introduction to Healthcare/Insurance fraud

  • a. What Is Healthcare/Insurance fraud?
  • b. What Does Healthcare/Insurance fraud Look Like?
  • c. Healthcare/Insurance fraud in the United States
  • d. Healthcare/Insurance fraud in International Markets
  • e. Who Commits Healthcare/Insurance fraud?
  • f. What Is Healthcare/Insurance fraud Examination?
  • g. Latest Trends & Challenges Globally in Health Insurance Fraud System
  • h. The Healthcare Continuum: An Overview
  • i. Healthcare/Insurance fraud Overview: Implications for Prevention, Detection, and Investigation

II. Defining Market Players within the Healthcare Continuum

  • a. The Patient
    • i. Who is the patient?
    • ii. What are some examples of patient fraud?
    • iii. How does the patient role relate to other healthcare continuum players?
  • b. The Provider
    • i. Who is the provider?
    • ii. What are some examples of provider fraud?
    • iii. How does the provider role related to other healthcare continuum players?
  • c. The Payer
    • i. Who is the payer?
    • ii. What are some examples of payer fraud?
    • iii. How does the payer role related to other healthcare continuum players?
  • d. The Employer/Plan Sponsor
    • i. Who is the employer/plan sponsor?
    • ii. What are some examples of employer/plan sponsor fraud?
    • iii. How does the employer/plan sponsor role relate to other healthcare continuum players?
  • e. The Vendor and the Supplier
    • i. Who are the vendor and the supplier?
    • ii. What are some examples of vendor and supplier fraud?
    • iii. How do the vendor and supplier roles relate to other healthcare continuum players?
  • f. The Government
    • i. Who is the government?
    • ii. What are some examples of government fraud?
    • iii. How does the government role relate to other healthcare continuum players?
  • g. Market Players Overview: Implications for Prevention, Detection, and Investigation

III. Protected Health Information

  • a. How to Recognize & Avoid Health Insurance Fraud
  • b. Is Health insurance Fraud Victimless?
  • c. Health Insurance Portability and Accountability Act (HIPAA) of 1996
  • d. Audit Guidelines in Using PHI
  • e. Healthcare insurance Fraud: Penalties & Consequences
  • i. Global Perspective: compare and contrast
  • f. Cracking Down on Healthcare Insurance Fraud
  • g. Protected Health Information Overview: Implications for Prevention, Detection, and Investigation

IV. Health Information Pipelines

  • a. The Auditor’s Checklist
  • b. What Are the Channels of Communication in a Health Information Pipeline?
    • i. The patient
    • ii. The provider
    • iii. The employer/plan sponsor
    • iv. The vendor/supplier
    • v. The government plan sponsor
  • c. Unauthorized Parties
  • d. HIP Overview: Implications for Prevention, Detection, and Investigation

V. Accounts Receivable Pipelines

  • a. Overview of Healthcare Reimbursement
  • b. Types of Reimbursement Models
    • i. Fee-for-service model
    • ii. Prospective model
    • iii. Capitation-structured model
  • c. Data Contained in Accounts Receivable Pipelines
  • d. Accounts Receivable Pipelines by HCC Player
    • i. The patient
    • ii. The provider
    • iii. The payer
    • iv. The employer/plan sponsor
    • v. Other
    • e. ARP Overview: Implications

VI. Operational Flow Activity

  • a. Operational Flow Activity Assessment
    • i. The patient
    • ii. The provider
    • iii. The payer
    • iv. The employer
    • v. The “other”
  • b. OFA Overview: Implications for Prevention, Detection, and Investigation

VII. Product, Service, and Consumer Market Activity

  • a. Product Market Activity
  • b. Service Market Activity
  • c. Consumer Market Activity
  • d. PMA, SMA, and CMA Overview: Implications for Prevention, Detection, and Investigation
     
Morning Break & Networking
Session Two

VIII. Data Management

  • a. Data Management
  • b. Market Example: Setting Up a Claims RDBMS
  • c. Data Management Overview: Implications for Prevention, Detection, and Investigation
  • d. References

IX. National Infrastructure

  • a. Normal Profile of a Fraudster
    • i. What types of people or entities commit fraud?
    • ii. What is the key element of a fraudster?
  • b. Anomalies and Abnormal Patterns
  • c. Normal Infrastructure Overview: Implications for Prevention, Detection, and Investigation

X. Normal Infrastructure and Anomaly Tracking Systems

  • a. The Patient
    • i. Sample patient fraud scenarios
    • ii. Data management considerations
    • iii. The untold story
  • b. The Provider
    • i. Sample provider fraud scenarios
    • ii. Data management considerations
    • iii. The untold story
  • c. The Payer
    • i. Sample payer fraud scenarios
    • ii. Data management considerations
    • iii. The untold story
  • d. Organized Crime
    • i. Sample organized crime fraud scenarios
    • ii. Data management considerations
    • iii. The untold story
  • e. Normal Infrastructure and Anomaly Tracking Systems Overview: Implications for Prevention, Detections, and Investigation

XI. Components of the Data Mapping Process

  • a. What Is Data Mapping?
  • b. Data Mapping Overview: Implications for Prevention, Detection, and Investigation

XII. Components of the Data Mining Process

  • a. What is Data Mining?
    • i. Data mining in healthcare
    • ii. Components of the data mining process within the HCC
  • b. Data Mining Overview: Implications for Prevention, Detection, and Investigation

XIII. Components of the Data Mapping and Data Mining Process

  • a. Forensic Application of Data Mapping and Data Mining
  • b. Data Mapping and Data Mining Overview: Implications for Prevention, Detection, and Investigation

XIV. Data Analysis Models

  • a. Detection Model
    • i. Pipeline Application
    • ii. Detection Model Application
  • b. Investigation Model
  • c. Mitigation Model
  • d. Prevention Model
  • e. Response Model
  • f. Recovery Model
  • g. Data Analysis Model Overview: Implications for Prevention, Detection, and Investigation

XV. Clinical Content Data Analysis

  • a. What Is SOAP?
  • b. The SOAP Methodology
  • c. Electronic Records
  • d. Analysis Considerations with Electronic Records
  • e. Narrative Discourse Analysis
  • f. Clinical Content Analysis Overview: Implications for Prevention, Detection, and Investigation
     
Lunch Break & Networking
Session Three

XVI. Profilers

  • a. Fraud and Profilers
  • b. Medical Errors and Profilers
  • c. Financial Errors and Profilers
  • d. Internal Audit and Profilers
  • e. Recovery and Profilers
  • f. Anomaly and Profilers
  • g. Fraud Awareness and Profilers
  • h. Profiler Overview: Implications for Prevention, Detection, and Investigation

XVII. Market Implications

  • a. The Myth
  • b. “Persistent”
  • c. “Persuasive”
  • d. “Unrealistic”
  • e. The Types of Healthcare/Insurance fraud
  • f. Market Overview: Implications for Prevention, Detection, and Investigation

XVIII. Conclusions

  • a. Micromanagement Perspective
  • b. Micromanagement Perspective
  • c. Overview of Prevention, Detection, and Investigation
     
Evening Break & Networking
Session Four

I. Market Background

  • a. E – Health
  • b. How Is Electronic Health Information Created?
  • c. Information Technology Considerations
  • d. Review of Primary HCC Market Players
    • i. Patients
    • ii. Providers
    • iii. Third-party vendors
    • iv. Payers
  • e. Review of HCC Market Players
  • f. Major Initiative for E – Health
  • g. Audit Implication Overview

II. Industry Applications

  • a. Public Uses
  • b. Private Uses
  • c. Information Continuum
  • d. Market Standards and Initiatives
  • e. Agency for Healthcare Research and Quality
  • f. Health Level Seven
  • g. Certification Commission for Healthcare Information
  • h. Technology
  • i. Department of Defense Records Management Program
  • j. Association of Records Managers and Administrators
  • k. Audit Implication Overview

III. Impact of E – Health on Case Management

  • a. Financial Picture
  • b. Hospital-based FCM Application
    • i. Background information and provider perspective
    • ii. Problem: Getting paid correctly for services provided
    • iii. Findings
    • iv. Additional findings
    • v. Summary
  • c. Consumer-based FCM Application
  • d. Market Problems: The Industry as It Operates Today
  • e. Consumer FCM Model
  • f. Healthcare Portfolio Application
  • g. Virtual Case Management
    • i. VCM Payer Model
    • ii. VCM Patient Model
    • iii. VCM Hospital Model
    • iv. VCM Physician Model
    • v. VCM Allied Health Services
    • vi. VCM Nontraditional Health Services Model
  • h. Audit Implication Overview
     
Day 2 - Monday 26 February, 2018
Session One

IV. Data in an E – Health Environment

  • a. Data Library
  • b. Data Intelligence
  • c. New Data
  • d. More New Data
  • e. Processed Data
  • f. Data Warehouse
  • g. Audit Implication Overview

V. Algorithms

  • a. Background
  • b. Understand Algorithms
  • c. Data Elements
  • d. Case Study
  • e. Algorithm Selection
  • f. Auditor Implication Overview
     
Morning Break & Networking
Session Two

VI. Data-driven Health Decisions in an E – Health Environment

  • a. Knowledge Models
    • i. Primary Healthcare Continuum
    • ii. Secondary Healthcare Continuum
    • iii. Information Continuum
  • b. Third-party Vendor Knowledge Model
  • c. Knowledge Models for White-collar and Organized Crime
  • d. Sample Identity Theft Case
  • e. Medical Identity Theft
  • f. How Medical Identity Theft Occurs
  • g. Damages to Primary Victims
  • h. Medical Identity Theft from a Consumer Perspective
    • i. When the consumer is not aware
    • ii. When the consumer is involved
    • iii. When an individual wants products or services
  • i. Damages to Secondary Victims
  • j. Medical Identity Theft from an Entity’s Perspective
  • k. Auditor Considerations
  • l. Sample Fraud Case
  • m. Sample Pharmaceutical Fraud Case
  • n. Audit Implication Overview
  • o. Examples of Worldwide Activity

VII. Analytic Tools and Audit Checklists

  • a. E – Health and Healthcare Business Processes
  • b. Patient Business Process
    • i. Problem #1: Financial Case Management Advocacy
    • ii. Problem #2: Clinical Case Management Advocacy
  • c. Provider Business Process
    • i. Problem #1: Lack of Electronic Internal Controls
    • ii. Problem #2: Lack of Internal Controls with User Identity
    • iii. Problem #3: Lack of Internal Controls for Services Provided and Charged
  • d. Payer Business Process
    • i. Problem #1: Use and Loss of Health Information – Handling Subcontracted Vendors
    • ii. Problem #2: Lack of Insurance – Processing Fraudulent Claims for Enrolled Beneficiaries
  • e. Plan Sponsor Business Process
    • i. Problem #1: Employee Working Environments
    • ii. Problem #2: Employer Increase in Healthcare Expenditures
  • f. Third-party Vendor Business Process
    • i. Problem: Increase in Pharmaceutical Expenditures
  • g. Audit Implication Overview
     
Lunch Break & Networking
Session Three

VIII. Electronic Health Records

  • a. Current E – Health Offerings
  • b. Market Evolution
  • c. E – Health Content Standards
  • d. E – Health Offering Vulnerabilities
  • e. Audit Implication Overview
     
Evening Break & Networking
Session Four

IX. Healthcare Portfolio

  • a. Health Infomediary Support
  • b. PHR Attributes
  • c. Future Considerations
  • d. Major Market Activity
  • e. Compulsory Insurance Program: i.e. Medicaid & Medicare Fraud, Government sponsored Canada, and Germany
  • f. Audit Implication Overview

X. Conclusions

  • a. Market Overview
    • i Market standards
    • ii. Market conflicts
    • iii. Market intelligence
    • iv. Market audits
    • v. Market directions
  • b. Consumer Response to PHRs
  • c. Audit Implication Overview
     
Course Program
Time Topic
08:00 to 08:30Registration & Introduction
08:30 to 10:00Session One
10:00 to 10:15Morning Break & Networking
10:15 to 12:15Session Two
12:15 to 13:15Lunch Break & Networking
13:15 to 14:45Session Three
14:45 to 15:00Evening Break & Networking
15:00 to 16:30Session Four