Medical Insurance Fraud Detection, Prevention & Advanced Data Analytics Training Workshop

September 22-23, 2019, 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.
  • Illustrate how fraud detection and prevention techniques can be practically used through sample case studies
  • Provide exposure to the latest emerging technology (AI, Blockchain) trends and their application to optimize the fraud investigation
  • Develop fraud prevention procedures specific to the health care industry
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Instructor(s) of this course

Rebecca S. Busch

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
Shahzad Alam

Head of Anti-Fraud, Investigations and Medical Audit
at Oman Insurance Company, UAE
Expert in fraud management and a demonstrated history
of working in the global insurance industry Worked at:
ADNIC, Deloitte, KMPG, EY as Anti Fraud Expert

More Detail

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 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 course also provides exposure to the latest emerging technology trends and their application to optimize the fraud investigation. The course is embedded with several interactive practical case studies that illustrate to the audience how the fraud investigation techniques can be practically applied in a real-time environment. The ultimate goal is to encourage participants to see beyond the eclipse created by Healthcare/Insurance fraud and sharpen audit and investigation skills to identify incontrovertible truth.

After attending this course, participants will return with new knowledge and be able to:

  • Explain common health care fraud schemes.
  • Implement basic investigative strategies to enhance fraud detection and investigation.
  • Identify the steps in an investigative plan.
  • Identify common data analytic strategies to investigate a case.
  • Evaluate cases for merit.
  • Detect potential red flags in medical and billing records.
  • Identify appropriate resources to assist in fraud detection and investigation.

This program is appropriate for analysts, corporate executives, healthcare professionals, investigators, internal auditors for hospitals, medical offices and other health care organizations

  • Little or no investigative / health care / analytics expertise is  expected, terms and acronyms are defined, concepts are    explained in detail, and the education focus is on investigative skills.
  • Pre-requisites: There are no pre-requisite requirements to attend this program.
  • Third party Administrator (TPA)
  • 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

Course Fee $2,100/Participant

Individual
Book & pay on or before August 22, 2019
& get 10% discount USD 1,890/participant
Corporate (Group Discount)
5%
Additional discount on minimum of 2 Participants

 


Medical Insurance Fraud Detection, Prevention & Advanced Data Analytics - Course Schedule

Day 1 - Sunday 22 September, 2019
Opening Session

Registration and Intro

Session One

I.  Overview of fraud examination

  • a.  What Is Healthcare/Insurance fraud?   
  • b.  What Does Healthcare/Insurance fraud Look Like?   
  • c.  Who Commits Healthcare/Insurance fraud?   
  • d.  What Is Healthcare/Insurance fraud Examination?

II.  ACFE practice standards   

  • a.  Standards of Professional Conduct   
  • b.  Standards of Examination   
  • c.  Standards of Reporting
Morning Break & Networking
Session Two

I.  Implication of healthcare fraud and current global trends;    

  • a.  Healthcare/Insurance fraud in the United States   
  • b.  Healthcare/Insurance fraud in International Markets   
  • c.  Healthcare/Insurance fraud in GCC

II.  Spotlighting trends and emerging schemes in healthcare fraud;    

  • a.  Types of Healthcare Fraud Schemes   
  • b.  Healthcare Fraud Trends   
  • c.  Comments on Healthcare fraud from GCC perspective  

III.  Developing an anti-fraud culture and ethics    

  • a.  Creating a culture of Ethics and Compliance   
  • b.  Developing Anti-Fraud, Compliance and Ethics policies   
  • c.  Responding to Ethics Breaches and Non Compliance   
  • d.  Monitoring, Assessing and Remediating the program

 

Lunch Break & Networking
Session Three

I.  Fraud examination process   

  • a.  How to conduct a healthcare fraud examination?   
  • b.  Fraud Examination - evidence gathering principles   
  • c.  Fraud Examination - developing algorithms

II.  Advanced medical fraud prevention strategies   

  • a.  Indications of potential medical fraud   
  • b.  How can data analytics help?   
  • c.  Developing Fraud detection and fraud prevention strategies

III.  Medical audit/tools   

  • a.  Medical Audits Checklist   
  • b.  Medical Audit framework strategy   
  • c.  Commercial medical audit tools in the market
Evening Break & Networking
Session Four

I.  Case study work session practical work and interactive exercises   

  • a.  Understanding providers’ fraud patterns using historical claims data   
  • b.  Healthcare benefit plan audit – to study claims adjudication
Session Five

Covered by (Mr. Shahzad Alam, Head of Anti Fraud, Investigations and Medical Audit Unit, Oman Insurance Company)

The Changing Landscape of Medical Insurance Fraud in the UAE and GCC Region

  • Healthcare Insurance Fraud challenges and its Impact
  • Common Types/schemes of Health Insurance Fraud
  • Healthcare Fraud Prevention Partnership
  • Use of Data Analytics in Fraud Detection
  • All accompanied with Examples, Real life experiences and Group Discussion
Day 2 - Monday 23 September, 2019
Session One

I.  Conducting a comprehensive and integrated approach to healthcare fraud risk assessment (IIA Standards)   

  • a.  Healthcare Fraud Risk Assessment - Introduction   
  • b.  Fraud Risk Governance   
  • c.  Fraud Risk Assessment   
  • d.  Fraud Detection and Prevention   
  • e.  Fraud investigation and corrective action

II.  Medical fraud detection using advanced data analytics/data mining techniques   

  • a.  Identifying potential patterns of fraud and abuse in healthcare using  Predictive Analytics techniques
Morning Break & Networking
Session Two

I.  Healthcare insurance fraud challenges and its impact in Middle East

II.  Healthcare fraud prevention   

  • a.  Improving the efficiency of GCC health systems   
  • b.  Healthcare financing   
  • c.  Risk Management approach for health insurance fraud prevention     
  • d.  Use of technologies to optimize health fraud prevention
Lunch Break & Networking
Session Three

I.  Combating healthcare FWA with new technology (AI, BLOCHCHAIN or etc.); leveraging technology;
II.  Understanding health insurance regulations 
   

  • a.  Blockchain: the next horizontal innovation   
  • b.  AI – Benefits of Clinical analytics based on machine learning algorithms
Evening Break & Networking
Session Four

I.  Continued case study work session practical work and interactive exercises   

  • a.  Pharmacy claims audit – to understand audit benchmarks   
  • b.  Healthcare insurance claims Fraud detection – analytics model
Course Program
Time Topic
Day 1
08:00 to 08:30Registration & Introduction
Day 1-2
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
16:30 to 18:00Session Five