Together, Reducing Fraud Worldwide
7:30 a.m. - 8:00 a.m.
Registration and Continental Breakfast
8:00 a.m. - 9:20 a.m.
Overview of the U.S. Health Care Fraud The health care industry composes a huge and intricate portion of the economy. This introductory session will explain the relationship between the major figures in health care, including federal and state programs, private insurers, the third-party payer system and the claims reimbursement system.
Major Health Care Fraud InitiativesThere are several legislative efforts that have highly impacted the health care industry, and this session will build an understanding of each one. The topics include the Civil False Claims Act, as well as the latest major health care reform legislation, the Patient Protection and Affordable Care Act.
9:20 a.m. - 9:35 a.m.
9:35 a.m. - 10:55 a.m.
What is Health Care Fraud?Health care fraud takes numerous forms, and this session provides the legal definition for identifying fraudulent activity. This discussion will include federal and state violations.
Conducting a Health Care Fraud ExaminationHealth care fraud examinations are unique because of industry regulations and privacy issues. Here, we will talk about how to interview witnesses, collect evidence and access helpful resources to complete an investigation.
10:55 a.m. - 11:10 a.m.
11:10 a.m. - 12:30 p.m.
Common Schemes by ProvidersProviders—the parties that administer health care services—are the most common perpetrators of health care fraud. Here we will discuss the common schemes seen in the industry, such as false billing, code manipulation and durable medical equipment fraud.
Analyzing Data and Reporting ResultsOne of the obstacles in combating health care fraud is the heavy volume of data that examiners must sort through. This session will show you ways to access, analyze and report the information from a health care fraud examination.
12:30 p.m. - 1:30 p.m.
Lunch on Your Own
1:30 p.m. - 2:50 p.m.
Common Schemes by Other PartiesVirtually anyone involved in the health care industry can commit fraud. In this session, we will cover the common schemes by parties other than providers, such as fraud by beneficiaries, employees and insurers.
PreventionThe overarching tone set in recent health care reform is a movement away from the “pay-and-chase” mentality of fighting fraud, and toward a mindset of prevention. You will learn the recent trends in stopping fraud before it starts, as well as how to bring your prevention and ethics programs into compliance with new requirements.
2:50 p.m. - 3:05 p.m.
3:05 p.m. - 4:25 p.m.
The Legal Framework for Policing Health Care FraudWhether you work in the public or private sector, it is important to understand how law enforcement pursues health care fraud. This discussion will also look into the prosecution process and penalties for violations.
Practical ExercisesIn this final session, we will take a look at some practical exercises and real case examples of health care frauds. This collaborative discussion will demonstrate how to use the information from this course in the role of a fraud examiner.
© 2014 Association of Certified Fraud Examiners, Inc. All rights reserved.