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