Registration, Opening Remarks & Introduction

The Introduction to the problem of Medical Insurance Fraud

• Medical Insurance Fraud and its implications for society and economies
• Types of Fraud, waste, and abuse in healthcare insurance industry
  • Defining Market Players within the Healthcare Continuum
  • The Investigation Model

Proactive Casework and Detecting Fraud, Waste and Abuse

• The Evidence of Healthcare Fraud and How to Collect it
• Who, What, When Where, Why, How and How much?
• The processes and procedures in detecting fraud and building a case
• Utilizing Proactive Detection to avoid “pay and chase”

Healthcare Data Models

• Planning and examining data mapping and mining
• Doing your homework – assets, marital and financial status, bankruptcies/divorces/substance abuse data The “Auditor’s check list

Case Studies and Round Table Discussions

• Reviewing actual examples of successful investigations from predictive modeling
• Open discussion of experiences and successes with data mining in the UAE and the Middle East
• Prevention of fraud vs. “Pay and chase”
• Examples of large cases built solely on data analytics

Emerging Global Fraud Trends

• Telemedicine Fraud
• Pharmacy Fraud, Counterfeit Pharmaceuticals, and Emerging global trends
• International Organized Crime and Healthcare Fraud and Money Laundering
• Identity Theft and the Dark Web

Clinical Coding – Clinical Procedural Technology (CPT) and International Classification for Disease (ICD-10) codes

• The power of familiarization with coding
• Detection or Prevention?
• Setting the table with the Outlier
• Possible techniques to employ for enhancing interviews using data schematics

Group Review, Role Play of Interviews, Use of Analytics

• Group review and role play of Subject interviews
• Preparation for training in the use of analytics
• Preparing the evidence for the prosecutor/Auditor/Director

Impact of Covid-19 and other Pandemics on Global Healthcare

• The impact of Covid-19 and other pandemics on the global healthcare system: Fraud, waste and abuse in clinical responses.

Review of course, wrap up