WEBINAR: HEALTHCARE INSURANCE FRAUD DETECTION, INTERVIEWING TECHNIQUES AND BEHAVIORAL ANALYTICS

April 05-07, 2021, 1:00 PM - 5:40 PM, GULF/DUBAI 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

Course Fee $680/Participant


WEBINAR: HEALTHCARE INSURANCE FRAUD DETECTION, INTERVIEWING TECHNIQUES AND BEHAVIORAL ANALYTICS - Course Schedule

Day 1 - Monday 05 April, 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
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
Break (20 minutes)
Session Three (16:40 To 17:40)
  • 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
Day 2 - Tuesday 06 April, 2021
Session One (13:00 To 15:00)
  • 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
Break (20 minutes)
Session Two (15:20 To 16:20)
  • 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
Break (20 minutes)
Session Three (16:40 To 17:40)
  • 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
Day 3 - Wednesday 07 April, 2021
Session One (13:00 To 15:00)
  • 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
         
Break (20 minutes)
Session Two (15:20 To 16:20)
  • 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
Break (20 minutes)
Session Three (16:40 To 17:40)
  • 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
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