Medical Fraud Interviewing Techniques and Behavioral Analytics

Course Schedule

Day 1 - Wednesday 04 December, 2019
Opening Session

Registration and Intro

Session One

The Basics of Healthcare Insurance Fraud

  • The Fraud Triangle
  • Types of Fraud, waste and abuse in healthcare
  • Identifying the potential interviewee and Defining Market Players within the Healthcare Continuum
    • a. The Patient
      • i. Who is the patient? What are some examples of patient fraud?
    • b. The Provider
      • i. Who is the provider? What are some examples of provider fraud?
    • c. The Payer
      • i. Who is the payer? What are some examples of payer fraud?
    • d. The Employer/Plan Sponsor
      • i. Who is the employer/plan sponsor? What are some examples of employer/plan sponsor fraud?
    • e. The Vendor and the Supplier
      • i. Who is the vendor and the supplier? What are some examples of vendor and the supplier fraud?
  • Triparte Fraud
Morning Break & Networking
Session Two

Dissecting the Case and Planning the interviews

  • The Order and Cadence of multiple interviews     
  • Who, What, When Where, Why, How and How much?
  • The processes and procedures in building a case     
  • Understanding the order and exigency of various interviews
  • How to identify fraud when the documents appear correct and there is member collusion.
 Lunch Break & Networking
Session Three

The Basics of Forensic Interviewing

  • Discuss strategies for structuring interviews
  • Discuss when and where to conduct interview
  • Types of witnesses:  Whistleblower/Complainant;
  • Patients, Former Employees, Office staff, Subjects, family members
  • Behavioral Profiling to assist in the interview setting
Evening Break & Networking
Session Four

Case Studies and Round Table Discussions

  • Reviewing actual examples of successful interviews and failed interviews
  • Open discussion of experiences and successes with witness and patient interviews:
    • a. Age, Gender, Loyalty to Doctor, Juvenile, Disabled, telephonic?
    • b. Videos of various healthcare fraud interviews
    • c. Role Play of witness interviews in the classroom
    • d. Role play of patient interviews in the classroom
Day 2 - Thursday 05 December, 2019
Session One

Behavioral Analytics

  • How to Think Like a Fraudster
  • Planning and examining all potential outcomes of the interview
  • Doing your homework – assets, marital and financial status, bankruptcies/divorces/substance abuse
  • How to interview a Doctor with coders and attorneys present
 Morning Break & Networking
Session Two

Behavioral Analytics and the Role of Ethics

  • The power of building rapport in the interview
  • Accusations or “breathing room?”
  • Setting the table
  • Possible techniques to employ for contingent circumstances during the interview
 Lunch Break & Networking
Session Three

Legal Issues in Healthcare Fraud Investigations, Safeguarding your case within the law

  • How a fraudster’s defense council can be your asset
  • Avoiding Personal Health Information (PHI) in the interview
  • The legality of recording the interview:  pros and cons
  • The importance of case documentation used during the interview
  • The use of analytics and a statistician/peer reviews and anomalous status
 Evening Break & Networking
Session Four

Summary Review and Wrap up: Group Session

  • Group review and role play of Subject interviews
  • The interview:  a “non-accusatory conversation” vs an interrogation
  • Five obstacles to overcome in conducting a forensic interview
  • Five skillsets to develop in conducting successful forensic interviews
  • Emerging Commercial Anti-Fraud Technologies, (Blockchain, AI, Advanced Analytics, etc.)

Certificate Ceremonial

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 13:15 Lunch Break & Networking
13:15 to 14:45Session Three
14:45 to 15:00Evening Break & Networking
15:00 to 16:30Session Four