WEBINAR: Healthcare Insurance Fraud

January 18-20, 2021, 1:00 PM - 5:40 PM, GULF STANDARD TIME (UTC + 04:00)

Training Objectives

  • Introduction to fraud principles and Healthcare/Insurance fraud
  • Identify, describe, and assess healthcare/insurance fraud scenarios in all settings (provider, employer, patient, payer, government)
  • Develop and implement programs to identify healthcare/insurance fraud in all settings, and best practices to combat Healthcare/Insurance fraud
  • Learn investigative techniques to identify Healthcare/Insurance fraud
  • Develop writing skills in identifying and reporting Healthcare/Insurance fraud
Register Now Download Brochure

Instructor of this course

Rebecca S. Busch

RN, MBA, CCM, CFE, CPC, CHS-111, CRMA, CICA, FIALCP, FHFMA
CEO, Medical Business Associates, Inc.

Book Author of “Healthcare Fraud: Auditing & Detection Guide”
Faculty member of the Association of Certified Fraud Examiners
 

More Detail

When Willie Sutton, an infamous twentieth-century bank robber, was asked why he robbed banks, he replied, “Because that’s where the money is.’’ The healthcare/insurance industry, too, has lots of money – estimated to be a $2.9 trillion industry in 2015. How many of these annual healthcare/insurance dollars are attributed to fraud? About $25 million per hour is stolen in healthcare in the United States alone.

This course is designed to introduce the healthcare/insurance industry: a highly segmented market with high-dollar cash transactions, from a fraud, audit, and detection perspective. This course also teaches “what is normal” in the marketplace so that abnormalities become apparent. Healthcare/Insurance fraud prevention, detection, and investigation methods are outlined, as are different types of healthcare schemes, red flags to spot these schemes, and how Healthcare/Insurance fraud is ultimately stopped.

The ultimate goal is to encourage participates to see beyond the eclipse created by Healthcare/Insurance fraud and sharpen audit and investigation skills to identify incontrovertible truth.

Participants who complete the course will get an opportunity to:

  • Understand the basic concepts of fraud in Healthcare/Insurance
  • Understand scenarios that contributes to Healthcare fraud and differentiate between fraud and errors
  • Identify market players within a healthcare continuum and assess the risks associated with different entities and their role in a healthcare transaction
  • Evaluate the effectiveness of current policies to identify fraud, waste and abuse
  • Detect and prevent anomalies or abnormal patterns
  • Create policies and procedures to effectively tackle healthcare frauds and implement a robust mitigation plan to reduce the impacts of fraudulent activities
  • Development and execution of architectures, policies, practices, and procedures that properly manage the full data lifecycle needs of an enterprise
  • Review best practices in the industries and adopt fraud management techniques to protect the organization
  • Analyze real life cases
  • C-Level Executives:
    • Chief Auditors,
  • Directors, Heads, Partners, Officers & Coordinators of:
    •  
    • Revenue Cycle Management
    • Special Investigations Unit
    • Billers
  • Group discussions
  • Team building discussions
  • Online quizzes
  • Using brain storming techniques, images, graphics and video clips for quality learning
  • Feedback discussion of the previous day activities
  • Course material
  • Certificate of achievement

Webinars

How can I register for Webinar and how does the whole thing work?

You may register by email or online: 

To register by email:

Download the brochure and complete the registration form given as a last page of the brochure and email to training@acsmb.com

To register online:

Step 1 – Go to the course page and click ‘Register Now

Step 2 - Complete the registration form, read and check the ‘terms and conditions’ box and click on ‘Register’.  You’ll receive a confirmation email.   

Step 3 - Click on ‘Confirm’ in the confirmation email and you'll be taken to the login page. Login and click the "Add to Cart" button that suits your needs and click "Pay by Credit Card" to enter your payment details.  You'll receive a payment confirmation email as well as a Welcoming Package with the full itinerary.

Please check following questions to see how the whole thing works.

If you have any questions or need assistance, please and thank you reach us at training@acsmb.com

How soon I can login?

You will be able to login 10-15 minutes prior to each activity/session. Don’t take a chance, so better will be to login early.

How do I join webinar/meeting?

Joining is easy, just takes few seconds.

Just click the link in the invite that you will be provided with in email. You will proceed to your session immediately. Just remember to register first if attending a webinar.

How can I join Zoom meeting and what are the pre-requisites?

Please check the details as how to join the meeting at https://support.zoom.us/hc/en-us/articles/201362193-Joining-a-meeting

How do I ask the Instructor questions?

There will be a 'chat option on your screen. Type your question in the box and send it direct to the Instructor. The Instructor will address your question at the earliest and at an appropriate time during the presentation

Course Fee $800/Participant

Early Bird Discount
10% discount till Jan 06, 2021 to pay $720/participant

2+1 OFFER:
$1600 for 03 participants


WEBINAR: Healthcare Insurance Fraud - Course Schedule

Day 1 - Monday 18 January, 2021
Opening Session (12:45 To 13:00)

Opening Remarks  & Introduction

Session One (13:00 To 15:00)
  • Introduction to Healthcare/Insurance fraud
    • What Is Healthcare/Insurance fraud?
    • What Does Healthcare/Insurance fraud Look Like?
    • Healthcare/Insurance fraud in the United States
    • Healthcare/Insurance fraud in International Markets
    • Who Commits Healthcare/Insurance fraud?
    • What Is Healthcare/Insurance fraud Examination?
    • Latest Trends & Challenges Globally in Health Insurance Fraud System
    • Recent trends of Healthcare Fraud within the United States due to COVID-19
    • The Healthcare Continuum: An Overview
    • Healthcare/Insurance fraud Overview: Implications for Prevention, Detection, and Investigation
  • Defining Market Players within the Healthcare Continuum
    • The Patient
      • Who is the patient?
      • What are some examples of patient fraud?
      • How does the patient role relate to other healthcare continuum players?
    • The Provider
      • Who is the provider?
      • What are some examples of provider fraud?
      • How does the provider role related to other healthcare continuum players?
    • The Payer
      • Who is the payer?
      • What are some examples of payer fraud?
      • How does the payer role related to other healthcare continuum players?
    • The Employer/Plan Sponsor
      • Who is the employer/plan sponsor?
      • What are some examples of employer/plan sponsor fraud?
      • How does the employer/plan sponsor role relate to other healthcare continuum players?
    • The Vendor and the Supplier
      • Who are the vendor and the supplier?
      • What are some examples of vendor and supplier fraud?
      • How do the vendor and supplier roles relate to other healthcare continuum players?
    • The Government
      • Who is the government?
      • What are some examples of government fraud?
      • How does the government role relate to other healthcare continuum players?
    • Market Players Overview: Implications for Prevention, Detection, and Investigation
  • Protected Health Information
    • How to Recognize & Avoid Health Insurance Fraud
    • Is Health insurance Fraud Victimless?
    • Health Insurance Portability and Accountability Act (HIPAA) of 1996
    • Audit Guidelines in Using PHI
    • Healthcare insurance Fraud:Penalties & Consequences
      • Global Perspective:compare and contrast
    • Cracking Down on Healthcare Insurance Fraud
    • Protected Health Information Overview: Implications for Prevention, Detection, and Investigation

Quiz

Break (20 minutes)
Session Two (15:20 To 16:20)
  • Health Information Pipelines
    • The Auditor’s Checklist
    • What Are the Channels of Communication in a Health Information Pipeline?
      • The patient
      • The provider
      • The employer/plan sponsor
      • The vendor/supplier
      • The government plan sponsor
    • Unauthorized Parties
    • HIP Overview: Implications for Prevention, Detection, and Investigation
  • Accounts Receivable Pipelines
    • Overview of Healthcare Reimbursement
    • Types of Reimbursement Models
      • Fee-for-service model
      • Prospective model
      • Capitation-structured model
    • Data Contained in Accounts Receivable Pipelines
    • Accounts Receivable Pipelines by HCC Player
      • The patient
      • The provider
      • The payer
      • The employer/plan sponsor
      • Other
    • ARP Overview: Implications
  • Operational Flow Activity
    • Operational Flow Activity Assessment
      • The patient
      • The provider
      • The payer
      • The employer
      • The “other”
    • OFA Overview: Implications for Prevention, Detection, and Investigation
  • Product, Service, and Consumer Market Activity
    • Product Market Activity
    • Service Market Activity
    • Consumer Market Activity
    • PMA, SMA, and CMA Overview: Implications for Prevention, Detection, and Investigation

Quiz

Break (20 minutes)
Session Three (16:40 To 17:40)
  • Data Management
    • Data Management
    • Market Example: Setting Up a Claims RDBMS
    • Data Management Overview: Implications for Prevention, Detection, and Investigation
  • Normal Infrastructure
    • Normal Profile of a Fraudster
      • What types of people or entities commit fraud?
      • What is the key element of a fraudster?
    • Anomalies and Abnormal Patterns
    • Normal Infrastructure Overview: Implications for Prevention, Detection, and Investigation
  • Normal Infrastructure and Anomaly Tracking Systems
    • The Patient
      • Sample patient fraud scenarios
      • Data management considerations
      • The untold story
    • The Provider
      • Sample provider fraud scenarios
      • Data management considerations
      • The untold story
    • The Payer
      • Sample payer fraud scenarios
      • Data management considerations
      • The untold story
    • Organized Crime
      • Sample organized crime fraud scenarios
      • Data management considerations
      • The untold story
    • Normal Infrastructure and Anomaly Tracking Systems Overview: Implications for Prevention, Detections, and Investigation
  • Components of the Data Mapping Process
    • What Is Data Mapping?
    • Data Mapping Overview: Implications for Prevention, Detection, and Investigation
  • Components of the Data Mining Process
    • What is Data Mining?
      • Data mining in healthcare
      • Components of the data mining process within the HCC
    • Data Mining Overview: Implications for Prevention, Detection, and Investigation
  • Components of the Data Mapping and Data Mining Process
    • Forensic Application of Data Mapping and Data Mining
    • Data Mapping and Data Mining Overview: Implications for Prevention, Detection, and Investigation
  • Data Analysis Models
    • Detection Model
      • Pipeline Application
      • Detection Model Application
    • Investigation Model
    • Mitigation Model
    • Prevention Model
    • Response Model
    • Recovery Model
    • Data Analysis Model Overview: Implications for Prevention, Detection, and Investigation
  • Clinical Content Data Analysis
    • What Is SOAP?
    • The SOAP Methodology
    • Electronic Records
    • Analysis Considerations with Electronic Records
    • Narrative Discourse Analysis
    • Clinical Content Analysis Overview: Implications for Prevention, Detection, and Investigation

Quiz

End of day review and wrap up (Group Interactive Discussion)

Day 2 - Tuesday 19 January, 2021
Session One (13:00 To 15:00)
  • Profilers
    • Fraud and Profilers
    • Medical Errors and Profilers
    • Financial Errors and Profilers
    • Internal Audit and Profilers
    • Recovery and Profilers
    • Anomaly and Profilers
    • Fraud Awareness and Profilers
    • Profiler Overview: Implications for Prevention, Detection, and Investigation
  • Market Implications
    • The Myth
    • "Persistent"
    • "Persuasive"
    • "Unrealistic"
    • The Types of Healthcare/Insurance fraud
    • Market Overview: Implications for Prevention, Detection, and Investigation
  • Conclusions
    • Micromanagement Perspective
    • Micromanagement Perspective
    • Overview of Prevention, Detection, and Investigation

Quiz

Break (20 minutes)
Session Two (15:20 To 16:20)
  • Market Background
    • E – Health
    • How Is Electronic Health Information Created?
    • Information Technology Considerations
    • Review of Primary HCC Market Players
      • Patients
      • Providers
      • Third-party vendors
      • Payers
    • Review of HCC Market Players
    • Major Initiative for E – Health
    • Audit Implication Overview
  • Industry Applications
    • Public Uses
    • Private Uses
    • Information Continuum
    • Market Standards and Initiatives
    • Agency for Healthcare Research and Quality
    • Health Level Seven
    • Certification Commission for Healthcare Information
    • Technology
    • Department of Defense Records Management Program
    • Association of Records Managers and Administrators
    • Audit Implication Overview
  • Impact of E – Health on Case Management
    • Financial Picture
    • Hospital-based FCM Application
      • Background information and provider perspective
      • Problem: Getting paid correctly for services provided
      • Findings
      • Additional findings
      • Summary
    • Consumer-based FCM Application
    • Market Problems: The Industry as It Operates Today
    • Consumer FCM Model
    • Healthcare Portfolio Application
    • Virtual Case Management
      • VCM Payer Model
      • VCM Patient Model
      • VCM Hospital Model
      • VCM Physician Model
      • VCM Allied Health Services
      • VCM Nontraditional Health Services Model
    • Audit Implication Overview
  • Quiz
Break (20 minutes)
Session Three (16:40 To 17:40)
  • Data in an E – Health Environment
    • Data Library
    • Data Intelligence
    • New Data
    • More New Data
    • Processed Data
    • Data Warehouse
    • Audit Implication Overview
  • Algorithms
    • Background
    • Understand Algorithms
    • Data Elements
    • Case Study
    • Algorithm Selection
    • Auditor Implication Overview

Quiz
End of day review and wrap up (Group Interactive Discussion)

Day 3 - Wednesday 20 January, 2021
Session One (13:00 To 15:00)
  • Data-driven Health Decisions in an E – Health Environment
    • Knowledge Models
      • Primary Healthcare Continuum
      • Secondary Healthcare Continuum
      • Information Continuum
    • Third-party Vendor Knowledge Model
    • Knowledge Models for White-collar and Organized Crime
    • Sample Identity Theft Case
    • Medical Identity Theft
    • How Medical Identity Theft Occurs
    • Damages to Primary Victims
    • Medical Identity Theft from a Consumer Perspective
      • When the consumer is not aware
      • When the consumer is involved
      • When an individual wants products or services
    • Damages to Secondary Victims
    • Medical Identity Theft from an Entity’s Perspective
    • Auditor Considerations
    • Sample Fraud Case
    • Sample Pharmaceutical Fraud Case
    • Audit Implication Overview
    • Examples of Worldwide Activity
  • Analytic Tools and Audit Checklists
    • E – Health and Healthcare Business Processes
    • Patient Business Process
      • Problem #1: Financial Case Management Advocacy
      • Problem #2: Clinical Case Management Advocacy
    • Provider Business Process
      • Problem #1: Lack of Electronic Internal Controls
      • Problem #2: Lack of Internal Controls with User Identity
      • Problem #3: Lack of Internal Controls for Services Provided and Charged
    • Payer Business Process
      • Problem #1: Use and Loss of Health Information – Handling Subcontracted Vendors
      • Problem #2: Lack of Insurance – Processing Fraudulent Claims for Enrolled Beneficiaries
    • Plan Sponsor Business Process
      • Problem #1: Employee Working Environments
      • Problem #2: Employer Increase in Healthcare Expenditures
    • Third-party Vendor Business Process
      • Problem: Increase in Pharmaceutical Expenditures
    • Audit Implication Overview

Quiz

Break (20 minutes)
Session Two (15:20 To 16:20)
  • Electronic Health Records
    • Current E – Health Offerings
    • Market Evolution
    • E – Health Content Standards
    • E – Health Offering Vulnerabilities
    • Audit Implication Overview

Quiz

Break (20 minutes)
Session Three (16:40 To 17:40)
  • Healthcare Portfolio
    • Health Infomediary Support
    • PHR Attributes
    • Future Considerations
    • Major Market Activity
    • Compulsory Insurance Program:i.e. Medicaid & Medicare Fraud, Government sponsored Canada, and Germany
    • Audit Implication Overview
  • Conclusions
    • Market Overview
      • Market standards
      • Market conflicts
      • Market intelligence
      • Market audits
      • Market directions
    • Consumer Response to PHRs
    • Audit Implication Overview
Course Program
Time Topic
Day 1
12:45 to 13:00Registration & Introduction
Day 1-3
13:00 to 15:00Session One
15:00 to 15:20Break (20 minutes)
15:20 to 16:20Session Two
16:20 to 16:40Break (20 minutes)
16:40 to 17:40Session Three