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
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