Health Care Fraud




CPE Credit: 16
Course Level: Overview
Prerequisite: None

Health care costs are a top concern for both businesses and individuals, and for good reason: By the year 2019, total national health care spending is expected to exceed $4.57 trillion, representing 19.6 percent of the U.S. Gross Domestic Product. Health care companies and providers today face unique industry regulations, procedures and considerations, as well as a heightened potential for fraudulent activity. Consequently, fraud fighters need an in-depth understanding of the industry environment and the types of health care fraud that can occur, including how to prevent, detect and investigate them.

This two-day, instructor-led course is designed for anti-fraud and audit professionals who work in the payer, provider, vendor and employer benefit areas or advise clients who operate within the health care continuum. Get the targeted training you need to keep up with the latest fraud schemes and related laws affecting this highly complex profession. 


Upcoming Courses 

No courses are scheduled at this time. Please view our Calendar of Events for other upcoming seminars.


You Will Learn How To:  

Navigate the complex payment systems in the U.S. health care industry

Identify the common health care schemes committed by providers, beneficiaries and third parties

Categorize health care violations under the legal enforcement framework

Conduct a health care fraud investigation

Develop fraud prevention procedures specific to the health care industry 

Who Should Attend:  

Accountants, auditors, attorneys and investigators who service health care industry clients

Detectives and private investigators

Government investigators charged with identifying fraud or noncompliance with government-funded health care facilities and efforts

Internal auditors for hospitals, medical offices and other health care organizations

Public-sector investigators

Certified Fraud Examiners and other anti-fraud professionals 


Members: $695
Non-Members: $845 

CPE Credit


Field of Study
Specialized Knowledge 


Course Level



Advanced Preparation


Delivery Method

  Day One 
7:30-8:00 a.m.   Continental Breakfast   
8:00-9:20 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.

9:20-9:35 a.m.  Break  
9:35-10:55 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.

10:55-11:10 a.m.  Break  
11:10 a.m.-12:30 p.m. 

Common Schemes by Providers 

Providers—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.

12:30-1:30 p.m.  Group Lunch  
1:30-2:50 p.m. 

Common Schemes by Other Parties 

Virtually 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.

2:50-3:05 p.m.  Break  
3:05-4:25 p.m.  

The Legal Framework for Policing Health Care Fraud 

Whether 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.



  Day Two 
7:30-8:00 a.m.   Continental Breakfast   
8:00-9:20 a.m. 

Major Health Care Fraud Initiatives 

There 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.

9:20-9:35 a.m.  Break  
9:35-10:55 a.m. 

Conducting a Health Care Fraud Examination 

Health 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.

10:55-11:10 a.m.  Break  
11:10 a.m.-12:30 p.m. 

Analyzing Data and Reporting Results 

One 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.

12:30-1:30 p.m.  Lunch on Own  
1:30-2:50 p.m. 


The 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.

2:50-3:05 p.m.  Break  
3:05-4:25 p.m.  

Practical Exercises 

In 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.

Event Cancellation Policy 

Our cancellation policy is intended to keep costs low for attendees. Due to financial obligations incurred by ACFE, Inc. you must cancel your registration prior to the start of the event. Cancellations received less than 14 calendar days prior to an event start date are subject to a $100 administrative fee. No refunds or credits will be given for cancellations received on or after the start date of the event. Those who do not cancel and do not attend are responsible for the full registration fee.


Satisfaction Guarantee 

ACFE seminars are unmatched in scope and effectiveness and backed by our unconditional satisfaction guarantee. If you attend an ACFE event and are not completely satisfied, please contact an ACFE Member Services Representative at or call (800) 245-3321 / +1 (512) 478-9000.


NASBA CPEThe Association of Certified Fraud Examiners, Inc. is registered with the National Association of State Boards of Accountancy (NASBA) as a sponsor of continuing professional education on the National Registry of CPE Sponsors. State boards of accountancy have final authority on the acceptance of individual courses for CPE credit. Complaints regarding registered sponsors may be submitted to the National Registry of CPE Sponsors through its website:


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