Opening Remarks  & Introduction

• 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

• 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

• 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
• 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

• 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
• 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
  • 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
• 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

• Advanced Investigation (Interviewing Techniques)
  • Introduction
  • Fraud Examination
    • Science behind fraud examination
    • Fraud examination vs. auditing
    • Interview vs. Interrogation
    • Fraud examination - Interview
  • Interview Goals
    • Steps involved in fraud examination
    • Interview process
    • Who should conduct the interview?
    • Sequence of Interview
    • When should the interview take place?
    • Interviewing – Planning
    • Duration of the Interview
    • The Interview setting
    • Interview Common Protocol
  • Sample Case
    • Sample case – Background
    • Sample Case -Who needs to be interviewed?
    • Sample Case - Planning is key
    • Sample Case - The Interview setting
    • Legal Warnings
    • How to Conduct an Effective Interview
    • Preparing Interview Questions
    • Types of Interview Questions
       

• Advanced Investigation (Interviewing Techniques) and Behavioral Analytics
  • Behavioral Analytics
    • What is behavioral analytics
    • Aspects of behavioral analytics
  • Persuasive Interviews
    • Effective persuasion methods
• Detecting Deception using Behavior Analytics
  • Verbal cues
  • Gestures and body movements
  • Paralinguistic and other specific traits

• Retrieval of Information from the Interviewee
  • Advanced Interviewing Techniques
  • Sample Case
    • Case Background
  • Sample Interview Questions
    • Management of Luke Technologies
    • Employee Interview questions
    • Interview Questions to the Suspect
    • Provider interview questions
    • Interview Findings
• Interview Memo
  • Analyzing the interview statements
  • Reviewing the statement
• Interview Report
  • Review of course and Q/A