Registration and Intro

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

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.

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

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

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

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

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

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