Day 1 - Sunday 25 February, 2018
Opening Session
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