Conference Sessions

Level I
Basic programs where little or no investigative, health care and/or IT expertise is expected, terms and acronyms are defined, concepts are explained in greater detail, and the education focus is on investigative skills.

Level II
Programs where some investigative, health care and/or coding expertise is assumed and training content is focused on the investigative process, using case examples to highlight investigative strategy and techniques.

Level III
Training designed to meet the needs of health care fraud senior investigators and managers, with a focus on synthesizing ideas and exploring strategies, concepts and information needed to direct a health care fraud investigative unit.

Note, audio and/or video recordings of NHCAA's Annual Training Conference sessions, general or break-out, are not allowed.

Search by Track:
Clinical Issues for the Health Care Fraud Investigator
Detecting and Investigating Dental Fraud
Fraud Schemes and Investigative Skills
Fraud in the Medicaid Program
Pharmacy & Part D Fraud
Legal, Management & Compliance
Life, Disability & Workers' Compensation
Anti-Fraud Technology Solutions

View ATC Schedule-at-a-Glance

 

 

Chiropractic FWA Trends AHFI Path
Wednesday, 9:00 a.m. - 10:15 a.m.
Level II

Dan Bowerman, DC, FACO, CPC, AHFI
Consultant, Expert-Opinions

Howard Levinson, DC, DC, AHFI, CFE, DABFP, CPC
Clinical Director, Fraud Investigations, WellPoint, Inc.

Discover emerging FWA trends in chiropractic services in the post Affordable Care Act world. Faculty will impart the investigative skills necessary to uncover cloaked services, including those services provided by other disciplines and specialties. Case examples of investigations and prosecution will reinforce the concepts presented.

Trends and Schemes in Functional Medicine: Micronutrient Analysis and Hormonal Therapies
Wednesday, 11:00 a.m. - 12:00 p.m.
Level III

Barbara Scott, BSN, RN, AHFI, CPC, CFE
Investigative Consultant, Blue Cross Blue Shield Association

In this session, faculty will examine the records and claims data from three functional medicine providers and illustrate patterns in the data to identify suspect claims for micronutrient testing and hormonal therapies. Faculty will also provide the rationale for denying claims for micronutrient analyses on the basis of coding analysis.

Treatment and Interventions in Autism
Wednesday, 1:30 p.m. - 2:30 p.m.
Level II

Lisa Cannady, BSN, RN, LNC
Principal Analyst, Special Investigations Unit, General Dynamics IT

The treatment of autism and related disorders is a growing business with great potential for fraud, waste and abuse (FWA). While an increasing number of state governments are mandating treatment coverage, the amount of misinformation available to parents and medical professionals also continues to grow, creating confusion and frustration. The presenter will review both evidence and non-evidence based practices along with resources to aid investigators in determining whether treatment can be considered legitimate and how to successfully negotiate the sensitive area of investigating treatments for children. Current coding trends and potential areas for data mining will also be discussed related to these treatments.

Urine Drug Screens
Thursday, 8:15 a.m. - 9:30 a.m. | Friday, 9:45 a.m. - 11:00 a.m.
Level II

Kristine Bordenave, MD
Medical Director, Humana

Ksenia Coble, RN, CPC
Clinical Advisor, Humana, Inc.

Identify the different kinds of drug screens: who orders them and why, how to determine which tests are necessary and which are questionable and how to spot a laboratory's abusive billing patterns.

Anesthesiology & Pain Management AHFI Path
Thursday, 10:15 a.m. - 11:15 a.m.
Level III

Jeffrey Livovich, MD
Medical Director, Aetna

Assemble a thorough list of fraud challenges in the specialties of anesthesiology and pain management including a look at guidelines for appropriate utilization, monitored anesthesia care (MAC) utilization, obstetric anesthesia coding and usage, mobile anesthesia transportation and set-up guidelines.

Fraud in the Emergency Department
Thursday, 10:15 a.m. - 11:15 a.m.
Level II

Dennis P.H. Mihale, MD, MBA
Chief Medical Officer, Starus Medical Group

Casey H. Chandler, JD
FWA Product Manager, Xerox

The Centers for Medicare & Medicaid Services (CMS) directed hospitals to develop policies for coding and billing of the Emergency Department Facility Claims. CMS issued guidelines to hospitals that allowed them to create their own protocol to determine the level of facility claim (service) based on facility resource consumption, not physician resource consumption. Because CMS did not issue a national guideline and each hospital was allowed to create its own set of internal guidelines, many payers have not attempted to audit Emergency Department Facility coding and billing. There are recent examples of audits conducted at hospitals which discovered flagrantly improper coding of services and overbilling by millions of dollars. This session will discuss how to assess hospital compliance with CMS guidelines, proper documentation, appropriate staff utilization of ED level codes and associated accurate billing.

Interventional Radiology
Thursday, 11:30 a.m. - 12:30 p.m.
Level II

Karna Morrow, CPC, RCC, CCS-P
Senior Consultant, Coding Strategies, Inc.

Expert faculty will demonstrate the potential for upcoding and incorrect modifier usage for procedures such as ultrasound guidance, angiography, thrombolysis and ablation. Participants will walk away with an understanding the procedures and codes to be able to detect creative documentation.

Examining Schemes in Podiatry
Thursday, 2:00 p.m. - 3:00 p.m.
Level III

Gary Cicio, DPM, DABFAS, CPC
Clinical Director, Fraud Investigations, WellPoint, Inc.

NHCAA's 2013 Medical Director of the Year explains two emergent foot and ankle schemes. The first, CPT "cloaking" of the subtalar arthroeresis procedure includes a description of the procedure, the likely candidates, how and where it is performed and the codes used to cloak the service. The second, radiofrequency lesioning of real or imagined peripheral nerves of the foot, examines which codes are billed, what ICDM diagnoses are submitted and why the billing is inappropriate.

Determine the Fraud Starting Point AHFI Path
Thursday, 3:30 p.m. - 5:00 p.m.
Level II

Rick Wakefield, JD, DC, PA
President, International Healthcare Consultants, Inc.

Faculty will demonstrate the pairing of common therapeutic codes to diagnostic codes and discuss the therapeutic codes that are used inappropriately with other therapeutic codes. Attendees will examine the point at which the inappropriateness of the billing grows to the level of fraudulent billing and how to recognize it. Through examples faculty will highlight how to identify billing for services not rendered, ghost patients, and how to use the medical records to conduct an EUO. Video clips will be used to compare equipment descriptions to the results of a clinic inspection, confirm that the patient was in attendance, corroborate the therapist activities, and impeach the patient when necessary. Other topics include: bundling and unbundling, lack of medical necessity, improper CPT coding for treatment, up-coding services and improperly attended versus unattended procedure coding.

 

Dental Director's Quick Hits Panel
Wednesday, 9:00 a.m. - 10:15 a.m.
Level III

Stewart Balikov, DDS, AHFI
National Dental Director Utilization Management, Aetna, Inc.

George Koumaras, DDS, AHFI
National Dental Director, WellPoint, Inc.

Katina Spadoni DDS,CDC,AHFI
Dental Consultant, Delta Dental of Illinois

Dental Directors supporting NHCAA Member Organization SIUs will discuss dental claim they are currently seeing in their networks, and offer suggestions on how to investigate dental claims in future investigations. Faculty will answer audience inquiries on dental issues in current cases.

Identifying Abuse of Dental Codes AHFI Path
Wednesday, 11:00 a.m. - 12:00 p.m.
Level II

Kim Brown, RDH, AHFI
Clinical Fraud Analyst, Delta Dental of Virginia

Patricia Shifflett, RDH, AHFI
Clinical Fraud Analyst, Delta Dental of Virginia

Abuse of CDT procedure codes is far more difficult to discover and prove than an obvious case of fraud, such as services not rendered. In this presentation, the CDT procedure codes that are most often abused and how they are abused will be discussed. Some of these codes pay a lower dollar insurance benefit and are usually not review by insurance companies therefore leading to overutilization. However, dental practices are encouraged to increase their billing of these codes to raise profit margins creating a perfect scenario for abuse. This abuse is rarely detected unless claims are reviewed. We will show how reviewing claim data for certain information, such as dates of service, procedure counts and sequence of treatment, can reveal these issues. Cases will be presented describing the schemes and our method of discovery.

Dental DME Billing
Wednesday, 3:10 p.m. - 4:10 p.m. | Thursday, 2:00 p.m. - 3:00 p.m.
Level II

Amy Krakower, Esq.
Investigator III, WellPoint, Inc.

Mary Morales, MHSA, RDH
Senior Investigator, WellPoint, Inc.

Faculty will discuss the emerging trend of dentists billing a patient's medical insurance for dental DME. Several complex schemes will be revealed, along with the corresponding codes used to inflate billing. Presenters will also emphasize the importance of a strong medical and dental SIU cooperative effort to thwart unnecessary or duplicative claims.

Dental Fraud Case Study LEL Path
Thursday, 10:15 a.m. - 11:15 a.m.
Level II

Joseph Parker
Special Agent, U.S. Department of Justice, Federal Bureau of Investigation

The case presentation will detail a 12 month investigation involving two employees of a dental office located in the Northern Virginia area. The program will cover the initiation of the case, from information received from two private insurance carriers regarding suspicious claims to the eventual judicial decisions. The program will include other investigative steps including the execution of search warrants, subpoenas and an NHCAA alert. At the conclusion of the case, both employees received Federal jail time and were ordered to pay over $230,000 in restitution.

Dental Benefits and the ACA Mgmt Path
Thursday, 11:30 a.m. - 12:30 p.m.
Level II

Kris Hathaway
Director of Government Relations, National Association of Dental Plans

Stewart Balikov, DDS, AHFI
National Dental Director Utilization Management, Aetna, Inc.

The passage of the ACA expanded insurance to millions of Americans and included pediatric dental benefits as part of the Essential Health Benefits package. As each state, working within HHS' guidance, sets its own specific interpretation of the benefits, insurers can expect a variety of medical necessity determinations which causes potential vulnerabilities than can be exploited. In this session faculty will explain the nuances of the dental benefit and how to prepare for potential abusive billing.

 

Joint Part C SIU/ Law Enforcement Investigations LEL Path
Wednesday, 9:00 a.m. - 10:15 a.m.
Level II

Ian Ives
Special Agent, U.S. Department of Health & Human Services, OIG-OI

Shannon Muldrow
Special Agent, U.S. Department of Justice, Federal Bureau of Investigation

Joseph Popillo, AHFI, CPC-A, CPCO
Director of Health Plan Operations, Health First Health Plans

Learn the best practices in working Medicare Part C investigations jointly with SIUs and multiple law enforcement agencies. Based on case related experience, hear from the perspective of a SIU Director, HHS-OIG-OI Agent, and FBI agent about the best strategies in successfully bringing a Medicare Part C case from the SIU unit to law enforcement agencies for prosecution. Gain a general understanding of Medicare Part C, case initiation, and types of fraud in Part C cases. Learn the best method of referring SIU cases to law enforcement agencies, the types of information needed by law enforcement, and the best form of communication between SIUs and law enforcement agencies. Understand the most productive investigative steps taken by SIU and law enforcement in reaching the goal of successful prosecution. Each member of the investigative team will provide the top lessons learned in this process.

Ambulance Fraud: a Growing Concern LEL Path
Wednesday, 9:00 a.m. - 10:15 a.m.
Level II

Christina Ramirez
Special Agent, U.S. Department of Health & Human Services, OIG-OI

Anderson Smith
Special Agent, U.S. Department of Justice, Federal Bureau of Investigation

Jeremy Thornton
Special Agent, U.S. Department of Health & Human Services, OIG-OI

Ambulance transportation fraud is one of the fastest growing problems in the United States. The ambulance industry, especially the area of ambulance transportation for dialysis patients, is extremely vulnerable to fraud and abuse. During the presentation faculty will discuss the various schemes employed by these offenders to illegally obtain reimbursement from Medicare and other insurance companies. Some of these schemes include payment of kickbacks, billing for services not rendered and transportation of patients who do not require an ambulance. The attendees will learn the requirements for reimbursement from Medicare as well as some indicators to help identify ambulance companies that may be committing fraud. Learn effective techniques used to investigate ambulance fraud cases. These points will be supplemented with real case examples.

Advanced Tools to Detect and Investigate Healthcare Fraud
Wednesday, 11:00 a.m. - 12:00 p.m.
Level III

Aneta Andros, MS, AHFI
Manager-SIU Analytics Team, CIGNA

Karen Weintraub, MA, AHFI, CPC-P, CPMA
Executive Vice President, SIU, Healthcare Fraud Shield

Special Investigation Units' (SIUs) across the spectrum are constantly faced with new FWA schemes and suspect providers. Although the typical FWA schemes are still prevalent, providers are becoming more cunning in their attempts to defraud payors. Therefore, SIUs need to utilize advanced techniques in detecting and investigating suspect activity. This course will provide both pre- and post-pay tactics that SIUs can utilize to identify suspect providers and, ultimately, change their behavior. Tools discussed during the session will include in-house data analytics, external analytics and methods derived from business partnerships, and various investigative tactics. This session will conclude by combining all of the tools and techniques discussed and showing how they were applied throughout a case investigation.

Key Issues Surrounding Fraud, Waste & Abuse in Home Healthcare Services
Wednesday, 1:30 p.m. - 2:30 p.m.
Level II

Nicole Cormier, LVN, RAC-CT, HCS-D
Manager, Clinical Audit, SCIO Health Analytics

Rodger Smith, JD
SVP, Payment Integrity, SCIO Health Analytics

Fee-for-service Medicare spent over $19 billion on home healthcare in 2011, which is up from just over $9 billion only a decade before. Although the implementation of the prospective payment system positively impacted utilization and spend in this area, spend for home healthcare is now above 1997 levels (before PPS), despite the fact that many beneficiaries have left traditional Medicare for Medicare Advantage products. This is one of the key reasons CMS has created a RAC specifically for home health, DME and hospice care. In addition, although Medicaid beneficiaries are not as heavy users, with the substantial expansion of Medicaid benefits, the need to review claims for home health services for potential fraud, waste and abuse in all products has never been stronger. This presentation will focus on key areas where home health services are paid inappropriately, including common schemes and abuses by providers and beneficiaries.

Understanding Medically Unlikely Edits
Wednesday, 3:10 p.m. - 4:10 p.m.
Level II

Jonnie Massey, CPC, CPC-P, CPC-I, CPMA, AHFI
Senior Investigator, Blue Shield of California

Kathleen Shaker, RN, BSN, CPC, CHC-H, AHFI
FWA Subject Matter Expert, Shaker Consulting Services

When providers submit their claims to the payer, they report the number of 'units' of service on the claims form. There are a number of fraud, waste and abuse 'units' schemes that have been plaguing payers for years. Learn about these schemes and new trends involving a wide range of codes including J codes, E/M services, anesthesia, laboratory services, and more. The faculty will also explain CMS' Medically Unlikely Edits (MUEs) and how they can be used as a tool to detect and curb this growing problem. The audience will be provided with many examples of schemes along with the related codes to take home to begin data mining.

2014 Investigation of the Year LEL Path
Wednesday, 3:10 p.m. - 4:10 p.m.
Level II

Welcome the recipients of NHCAA's 2014 Investigation of the Year Award and listen to the investigative strategies, multi-organization cooperation and case-building excellence that led to a successful resolution, as well as to the coveted NHCAA honor.

Health IT and the Impact on Investigations LEL Path
Thursday, 8:15 a.m. - 9:30 a.m. | Friday, 9:45 a.m. - 11:00 a.m.
Level II

Daniel Arce
Special Agent, U.S. Department of Health and Human Services, OIG-OI

Examine how health information technology (Health IT) is changing the face of health care investigations. Faculty will demonstrate techniques for detecting fraud schemes in Medicare data such as finding recruited beneficiaries, beneficiary who are recycled in and out of treatment, billing outliers, dates of services with same starting/ending dates, no previous mental health diagnosis, and geo-mapping to visually identify where beneficiaries live in correlation to a provider. The faculty will describe online data storage services and cloud email hosting and how law enforcement can use these services to its advantage. The presentation will also cover social media mining which when combined with private data searches can assist in subject location.

Bay Medical: A Brooklyn Strike Force Case Study LEL Path
Thursday, 8:15 a.m. - 9:30 a.m.
Level II

Joseph Napolitano
Assistant Special Agent in Charge, U.S. Department of Health and Human Services, OIG - OI

Kimberly Delaney
Special Agent, U.S. Department of Health and Human Services, OIG-OI

Kathryn Batt
Special Agent, U.S. Department of Justice, Federal Bureau of Investigation

Examine a complex case that involved a Brooklyn medical clinic, a "no-show" physician, organized crime co-conspirators and unscrupulous beneficiaries. The government investigation included the use of a court-ordered audio/video recording device hidden in a room at the clinic in which the conspirators paid cash kickbacks to corrupt Medicare beneficiaries, and uncovered a network of external money launderers who issued checks to shell companies to hide the clinic's fraudulently obtained health care proceeds. This complex investigation and subsequent successful prosecution identified $77 million in false billings and netted a 151 month sentence for the physician.

Making the Case with Data: Two Case Studies LEL Path
Thursday, 8:15 a.m. - 9:30 a.m.
Level II

Laura Cordova
Assistant Chief, Health Care Fraud, Criminal Division, Fraud Section, U.S. Department of Justice

Catherine Dick
Assistant Chief, Health Care Fraud, Criminal Division, Fraud Section, U.S. Department of Justice

Federal prosecutors will present case facts and investigative details with an emphasis on the role data plays in investigations. Using two case studies from recent trials involving community mental health center fraud and home health care fraud, faculty will demonstrate best practices in the use of data to investigate and successfully prosecute these cases.

Impact of ICD-10 on the SIU Mgmt Path
Thursday, 10:15 a.m. - 11:15 a.m.
Level II

Jonnie Massey, CPC, CPC-P, CPC-I, CPMA, AHFI
Senior Investigator, Blue Shield of California

Participants will learn about the mandatory change to ICD-10 Coding and how that will impact investigations. Significant changes to both the format of the new codes as well as the required documentation to accurately code medical claims will be discussed. New terms specific to ICD-10-CM will be reviewed. Changes to auditing and investigations will be examined giving the investigators a better understanding of this landmark coding change.

Sober Homes
Thursday, 10:15 a.m. - 11:15 a.m. | Thursday, 2:00 p.m. - 3:00 p.m.
Level II

David S. Popik, CFE
Sr. Director, Special Investigations Unit, Florida Blue

Amanda Brown, AHFI
Compliance Officer, New Directions Behavioral Health

Joshua Orr
Assistant Attorney General, Medicaid Fraud Division, Office of the Attorney General

Sober living facilities offer recovering addicts a place to live and to continue their sobriety, but can find themselves caught in the financial alliance between sober homes and private drug-testing labs seeking revenue for repeated urine drug screens from federal and private insurance. Faculty identify how the scheme is comprised, the various payers in the scheme and how to identify and prevent abuse.

Use of Extrapolation for Recovery and Prosecution Mgmt Path
Thursday, 11:30 a.m. - 12:30 p.m.
Level III

Kristen Valdes
VP, Operations & Technology, XLHealth

Mark Starinsky, AHFI, CFE
Supervisor, Anti-Fraud Services, General Dynamics Information Technology

Health payers who have invested in creating a solid fraud, waste and abuse (FWA) program have long used sampling in their investigations. However, determining which are the most effective sampling methodologies, and validated to withstand litigation, can be difficult. In this session, faculty will describe how extrapolation is used in both public and private investigations and recoveries and how to evaluate and defend the effectiveness of extrapolation methods.

Behavioral Health Audits AHFI Path
Thursday, 11:30 a.m. - 12:30 p.m.
Level II

Amanda Brown, AHFI
Compliance Officer, New Directions Behavioral Health

Jonnie Massey, CPC, CPC-P, CPC-I, CPMA, AHFI
Senior Investigator, Blue Shield of California

Uncover the unique challenges auditing behavioral health providers, including privacy laws, up-coding, and face to face vs. telephone treatment. Using audit examples and sample medical records faculty will highlight how to identify red flags in the records, and recount examples of successful strategies to counter provider resistance to record access.

Fraud Schemes in other Countries
Thursday, 2:00 p.m. - 3:00 p.m.
Level II

Leiza McGrath
Manager, Investigative Services & Web Controls, Sun Life Financial

Simon Peck, MD
Head of Investigations, AXA PPP Healthcare

SIU directors from Canada and the UK share emerging fraud trends identified in their respective countries as well as instances of cross-border fraud encountered.

Emerging Fraud Schemes in Medicare LEL Path
Thursday, 3:30 p.m. - 5:00 p.m.
Level II

Jennifer Trussell
Special Advisor, U.S. Department of Health & Human Services, OIG-OI

The session will explore emergent schemes impacting the Medicare and Medicaid program, and tips on the rapid identification of these schemes. Fraud challenges that will be the focus of tomorrow's investigations will be identified.

Operation Orange Squeeze: Using the Anti-Kickback Statute to Attack Corruption in the Healthcare Industry LEL Path
Thursday, 3:30 p.m. - 5:00 p.m.
Level II

Joseph Mack, JD
Assistant United States Attorney, U.S. Attorney's Office, District of New Jersey

Scott McBride
Assistant United States Attorney, U.S. Attorney's Office, District of New Jersey

Eric Rubenstein
Special Agent, U.S. Department of Health & Human Services, OIG-OI

The session will review the elements of the Federal Anti-Kickback statute and explain the unique aspects of the investigative process for these types of violations. Faculty will examine current case models involving a multi-million dollar kickback scheme where dozens of medical providers were paid cash in return for the referral of patients in need of radiological services. Through the use of an analysis of the investigation, including covert video, participants will learn the necessary steps required to create an airtight prosecution of such allegations.

 

Investigating Medicaid Fraud
Wednesday, 9:00 a.m. - 10:15 a.m.
Level II

Cherie Ottochian, CPC
Senior Investigator, Aetna

Briana Hollenbeck, MS, AHFI, CPC
Senior Investigator, Aetna

Investigating Medicaid fraud can be infinitely more complex due to more stringent regulations, rules differing vastly between states, and a population that lends itself to schemes different than commercial and Medicare. Faculty will discuss, from experience, the unique challenges surrounding fraud in Medicaid. Schemes will be discussed in terms of specific codes, data mining tips, and investigative examples to promote best practices in Medicaid fraud. Schemes that presenters will be discussing include but are not limited to: home health fraud, allergy testing/immunotherapy, pharmacy, and unnecessary ultrasounds.

Urine Drug Screens: A Case Study LEL Path
Wednesday, 11:00 a.m. - 12:00 p.m.
Level II

Kelly Hensley, AHFI
Investigator, Kentucky Office of the Attorney General Medicaid Fraud Control Unit

Paul McCaffrey, JD
Deputy Chief of Fraud Unit, Assistant United States Attorney, United States Attorney Office, Eastern District of Kentucky

Faculty will present a case that involved allegations that an addiction treatment clinic, and related laboratory, submitted, or caused the submission of, false or fraudulent claims to the Medicare and Kentucky Medicaid programs for quantitative urine drug testing that were unnecessary, upcoded and in violation of the Stark Law. Examine the investigative process that uncovered disregarded negative drug screens, lack of physician usage, delayed test results and medically unlikely edits. Hear the results and successful recovery of $15.7 million.

Detecting & Investigating Behavioral Health Fraud LEL Path
Wednesday, 1:30 p.m. - 2:30 p.m.
Level II

George Zachos
Assistant Attorney General, Chief, Medicaid Fraud Division of Massachusetts, Office of the Attorney General

Joseph Shea
Investigator Supervisor, Massachusetts Office of the Attorney General

Explore strategies used in detecting, investigating and prosecuting a range of fraudulent billing schemes that are perpetrated by mental health providers. These complex investigations, often involving multiple payers, require a mix of skillful investigative techniques and a thorough understanding of the unique legal issues involving privileged communications between patients and clinicians. As such, this presentation will focus on the use of investigative strategies designed to address challenges specific to the investigation and prosecution of fraud, waste and abuse within mental health programs. Faculty will discuss the best practices and lessons learned in prior cases, and highlight the investigation, prosecution and conviction of a licensed independent clinical social worker and his company.

Caregiver Fraud: So Hidden Yet So Costly
Thursday, 2:00 p.m. - 3:00 p.m.
Level II

Ramona Smith
Special Agent, Tennessee Bureau of Investigation

Examine a recent Medicaid fraud trend involving employees of a caregiver agency billing for hours not worked and employees using stolen identities to execute that fraud. Caregiver fraud often goes undetected and if found can take many hours of 'crunching numbers', serving subpoenas, reviewing documentation and conducting interviews to gather necessary evidence. Faculty will provide attendees with direction on how to approach the investigation and share best practices gleaned from investigations including spreadsheet organization, document comparison, and time record analysis to achieve successful prosecution.

Hospice Fraud in the Medicaid Program LEL Path
Wednesday, 3:10 p.m. - 4:10 p.m.
Level II

Sue Bartholomew
Supervising Deputy Attorney General, California Department of Justice, Bureau of Medi-Cal Fraud & Elder Abuse

Peter Parszik
Special Agent, California Department of Justice, Bureau of Medi-Cal Fraud & Elder Abuse

Christina Ramirez
Special Agent, U.S. Department of Health & Human Services, OIG-OI

Through multiple case examples, state and federal agents and prosecutors demonstrate techniques necessary for the successful investigation of hospice fraud. Attendees will walk away with a deeper understanding of fraud schemes involving the hospice benefit including capping patients, false charting, and continuous care.

 

Part D and J Code Schemes LEL Path
Wednesday, 9:00 a.m. - 10:15 a.m.
Level II

Kristin Bailey
Special Agent, U.S. Department of Justice, Federal Bureau of Investigation

Christopher Clark
Assistant U.S. Attorney, U.S. Department of Justice

Liz S. Santamaria
U.S. Department of Justice, Federal Bureau of Investigation

Attendees will learn emerging trends targeting Medicare Part C and Private Insurance, including J Code schemes. Attendees will learn how to identify potential fraud, steps to investigate fraud, and how to put together a case to refer to law enforcement. Faculty will walk through a recent case study involving HIV infusion fraud.

Latest Trends in Pharmacy Fraud, Waste and Abuse Audits
Wednesday, 11:00 a.m. - 12:00 pm.
Level II

Jessica Schmor, RN, AHFI, CPC, CCS
Executive Director, Amenity Consulting

Mike Debelle, MBA
Senior Manager, Optimity Advisors

Faculty will review the latest pharmacy Fraud, Waste, and Abuse trends, identification practices, and algorithm build. Participants will learn how to construct a robust Fraud, Waste, and Abuse audit program that does not simply focus on pharmacy claims, but includes often overlooked categories such as DME and the intersection of pharmacy and medical claims, and how to build an effective audit team across all audit disciplines. Throughout the session faculty will use case studies to support and reinforce the topics being presented.

Compounded Injectible Drugs
Wednesday, 1:30 p.m. - 2:30 p.m. | Thursday, 10:15 a.m. - 11:15 a.m.
Level III

Ayms Lang, MD, CPC, AHFI, CFE
Medical Director, WellPoint, Inc.

The presenter will identify emerging trends and schemes regarding compounded injectible drugs, specifically, testosterone pellets and hyaluronic acid. The discussion will cover topics of "drug piracy" and regulations unique to hyaluronic acid, which the FDA has classified as a device rather than a drug. These cases have escalated into a multi-state, multi-agency investigation.

Pharmaceutical Wholesalers and Part D Fraud LEL Path
Thursday, 8:15 a.m. - 9:30 a.m. | Friday, 9:45 a.m. - 11:00 a.m.
Level II

Stephen Mahmood
Special Agent, U.S. Department of Health & Human Services, OIG-OI

Daniel Crespi
Special Agent, U.S. Department of Health & Human Services, OIG-OI

Houston E. Ramsey, Jr.
Special Agent, U.S. Food & Drug Administration, OCI

The panel will present a case study focused on a pharmaceutical wholesaler located in Miami-Dade County, FL. The wholesaler provided fraudulent drug pedigrees and invoices to Medicare Part D providers in the South Florida area. These providers were submitting false claims to Medicare Part D plan sponsors and the fraudulent invoices/pedigrees were used to support the false claims. The topics to be covered include referrals to the OIG, Part D fraud and the need for fake invoices, FDA nexus and drug pedigrees, NBI-MEDIC coordination with PBMs, invoice analysis and invoice review, criminal prosecution and spinoff investigations.

Investigation Techniques for Part D Cases LEL Path
Thursday, 11:30 a.m. - 12:30 p.m.
Level II

Robert Breeden
Special Agent, U.S. Department of Health & Human Services, OIG-OI

Heather Tucci
Special Agent, U.S. Department of Health & Human Services, OIG-OI

The workshop will include how undercover operations can assist in the effective investigation and prosecution of physicians and civilians involved in the criminal distribution of narcotics. Faculty will demonstrate how this distribution results in the fraudulent use of the Part D program. The presentation will highlight those areas to focus an investigation and lessons learned from prior investigations, examining the overlap that exists between healthcare fraud in the Part D and Part B programs, and how to use that overlap to enhance your investigation.

 

10 Legal Issues to Watch AHFI Path Mgmt Path
Wednesday, 9:00 a.m. - 10:15 a.m. | Thursday, 8:15 a.m. - 9:30 a.m.
Level III

Brian Flood, AHFI
Partner, Husch Blackwell LLP

Explore emerging anti-fraud developments including recent court decisions and legislative and regulatory developments impacting today's fraud investigations.

Effective Use of Data in Prosecutions LEL Path
Wednesday, 11:00 a.m. - 12:00 pm.
Level III

Gejaa Gobena, JD
Deputy Chief, Health Care Fraud, U.S. Department of Justice, Criminal Division, Fraud Section

A federal prosecutor will provide an overview of the utilization of anomalies in claims data to initiate criminal investigations. Through examples of successful prosecutions, the presenter will address the use of data to identify different types of fraud schemes and the use of both data and summary charts as evidence at trial.

CMS Program Integrity Update LEL Path
Wednesday, 1:30 p.m. - 2:30 p.m.
Level II

Shantanu Agrawal, MD, MPhil
Deputy Administrator and Director, Center for Program Integrity, U.S. Department of Health & Human Services, CMS

CMS' leadership will discuss recent health care fraud detection and prevention activities, and ground-breaking information sharing initiatives.

Lessons learned from HEAT, the most successful federal health care fraud initiative in U.S. history. A blueprint for the future. LEL Path
Wednesday, 1:30 p.m. - 2:30 p.m.
Level III

Marc Smolonsky
Consultant, HMS, Inc.

In his former role as Associate Deputy Secretary of the U.S. Department of Health & Human Services, Marc Smolonsky was integral in the planning and implementation of HEAT, an unprecedented federal collaboration to combat health care fraud. Mr. Smolonsky will provide both a historical and current look at HEAT successes, technological solutions and the U.S. government's new emphasis on fraud prevention, and provide his view on necessary action to grow and improve the effort.

Preparing for Audits Group Discussion Mgmt Path
Wednesday, 3:10 p.m. - 4:10 p.m.
Level III

Katherine M. Leff, RN, ALHC, CLU, AHFI, CPC, CFE
Director, Special Investigations Unit, Caresource Management Group

Flora Focarino, AHFI
Corporate Director, Special Investigations Unit, Excellus Blue Cross Blue Shield

Seasoned SIU directors will share preparation strategies when faced with federal or state audits. In this interactive session, the panelists and the audience will share expertise, lessons learned and engage in open discussion on best practices.

Compliance and the SIU Mgmt Path
Thursday, 10:15 a.m. - 11:15 a.m.
Level III

Mary L. Beach, AHFI, CFE
AVP, SIU/Medicaid Business Unit, WellPoint, Inc.

Ralph J. Carpenter
Director, Special Investigations Unit, Aetna

Darrell Langlois, AHFI, CPA, CIA
VP, Compliance, Privacy & Fraud, Blue Cross Blue Shield of Louisiana

Rick Munson, AHFI
Vice President, Investigations, UnitedHealthcare

Recent regulation focused on anti-fraud compliance has blurred the lines between traditional compliance activity and the role of the SIU. Faculty from leading health plans will share their experiences and lead group discussion on both the challenges and the benefits of the SIU's expanding compliance responsibility.

The ERISA Preemption Challenge AHFI Path Mgmt Path
Thursday, 11:30 a.m. - 12:30 p.m.

Carolyn Ham, JD, AHFI
Associate General Counsel, Optum

Most employer-sponsored health plans are governed by ERISA, the federal Employee Retirement Income Security Act. In order to permit employers to offer consistent health benefits to employees living in different states, the law grants broad preemption of state insurance laws to those plans. However, recently some creative attorneys for healthcare providers have argued that ERISA preempts efforts by Plans and/or Plan Administrators to recover overpayments. This workshop will begin with a basic overview of ERISA, its equitable remedies and its relationship to state insurance laws. It will then analyze several recent class action lawsuits filed by healthcare providers challenging payers' overpayment activities in which the providers claim that ERISA prevents payers from recovering overpayments. Hear how the Courts are ruling on this novel theory. Gather tips on framing your overpayment recoveries to avoid this challenge.

Fraud Under the Affordable Care Act: Year One Mgmt Path
Thursday, 3:30 p.m. - 5:00 p.m.
Level III

Carolyn Ham, JD, AHFI
Associate General Counsel, Optum

Individuals and small groups are now able to obtain health insurance with no pre-existing conditions and very limited underwriting through state health care exchanges. This workshop will explore how this change will impact the motivations and actions of individuals and small group employers and outline strategies to identify and prevent fraudulent claims. For example, we expect an increase in the amount of theft of insurance information since under HCR, an uninsured individual could face penalties as well the inability to obtain healthcare. The availability of tax credits for insurance premiums may lead to increased identity theft to commit tax fraud.

 

Life Insurance - Foreign Death Investigations
Wednesday, 11:00 a.m. - 12:00 p.m.
Level II

Richard J. Marquez
Managing Director, Diligence International Group LLC

The session will focus on the detection process used to investigate suspicious claims associated with individual life claims. Challenges investigating foreign death claims will be examined, uncovering whether the insured is alive or dead.

Disability and Workers Compensation Schemes AHFI Path
Wednesday, 1:30 p.m. - 2:30 p.m.
Level II

Kyson Johnson
Texas Department of Insurance

Join prosecutor Johnson as he recounts examples of disability and workers' comp fraud, unwinding labyrinth scams that constitute some of the most elaborate, bizarre white-collar crimes.

Maximizing Witness Value during Patient and Provider Interviews
Wednesday, 3:10 pm. - 4:10 p.m.
Level II

Brent Walker, AHFI
Regional Manager, Investigative Services, Travelers Insurance

Mitchell Sherrod, AHFI
Medical Fraud Investigator, Travelers Insurance

Faculty prepare a deep dive into how to approach the patient or provider, the need and strategies to obtain evidentiary value from an interview and how to maximize witness cooperation from the unique roles of patients and providers during a fraud investigation.

Emerging Trends in Workers' Compensation Fraud
Thursday, 11:30 a.m. - 12:30 p.m.
Level II

Lisa C. Gallagher, RN, BSN, JD, CFE
Assistant Vice President, Chief Investigative Counsel, Insurance Fraud Bureau of Massachusetts

Kevin Richard, CIFI
Lead Investigator, Provider Fraud Unit, Insurance Fraud Bureau of Massachusetts

Faculty will identify recent trends in provider and claimant fraud in workers compensation, and those schemes that impact and cross over to multiple line of business including auto, disability and life insurance.

 

End to End Risk Mitigation of Improper Payments
Presented by Emdeon, an NHCAA Platinum Supporting member
Wednesday, 9:00 a.m. - 10:15 a.m.
Level II

James McCall, AHFI
Director, Payment Integrity, Emdeon

David V. Cardelle, R.Ph.
Vice President, Operations, Payment Integrity, Emdeon

The risk of loss to improper payments includes a wide range of access points, from simple miscoding to highly complex criminal schemes. A comprehensive end to end process can help develop an effective risk mitigation program; this process includes action in each of four distinct phases: Avoid errant disbursements pre payment; Prevent inappropriate payments; Detect high risk behaviors post payment; Inspect and Audit rendered services. Learn more about an innovative approach to cost avoidance strategies and recommended best practices for developing an end to end risk management program and help reduce unnecessary losses.

Vulnerability Assessments and Provider Risk Statistics
Presented by Truven Health Analytics, an NHCAA Platinum Supporting member
Wednesday, 9:00 a.m. - 10:15 a.m.
Level II

Mark Gillespie
Senior Director, Truven Health Analytics

Jillian Thomas, AHFI
Team Lead, Truven Health Analytics

Fraud schemes in healthcare continue to evolve at a staggering rate. With the impact of ACA and the increased enrollments, the payer community overwhelmingly agrees that vigilance in staying abreast of the latest innovations in detecting and deterring these intrusions is a must. During this session, faculty will review a proven approach to baseline, describe, and prioritize payment integrity risk in your provider population, as well as successful intervention strategies. Truven will also review informative national provider risk statistics and how this information can be useful to you in monitoring and managing the risk of your providers. Recognized as an industry leader in Payment Integrity, Truven Health has been helping State and Federal agencies, Employers, and Health Plans in the detection, recovery, and prevention of fraud, waste and abuse for more than 30 years.

Moving Beyond Big Data: Integrated, Intelligent, and Interactive Analytics
Presented by Verisk Health, an NHCAA Platinum Supporting member
Wednesday, 11:00 a.m. - 12:00 p.m.
Level II

Doug Coombs
Vice President, Fraud Solutions, Verisk Health

Christa J. Jewsbury, JD, CFE
Director, Special Investigations Unit, Humana

Shuying Shen
Lead Analytic Scientist, Verisk Health

As the complexity of fraud, waste and abuse (FWA) schemes continues to intensify, the analytics required to prevent these types of schemes must also evolve. This 60-minute session will examine how analytics that leverage integrated data, intelligent metrics, and interactive visualizations can be used to more effectively detect and prevent fraudulent schemes and trends.

Data Analysis That Works: Using Simple Approaches to Communicate with Prosecutors and Jurors
Presented by HMS, Inc, an NHCAA Platinum Supporting member
Wednesday, 1:30 p.m. - 2:30 p.m.
Level II

Stephen Quindoza
Medicare Operations Coordinator, HMS, Inc.

Katherine Ho
Assistant U.S. Attorney, U.S. Department of Justice

Effective healthcare fraud investigations have always been about finding contradictions to reality -- such as suspicious codes and too many hours billed -- and tracing them back to prosecute wrongdoing. But today's investigators have new approaches to better identify these contradictions. In this session, Katherine Ho of the U.S. Attorney's Office in Orlando and Stephen Quindoza of HMS will identify the most powerful and practical methods to communicate with prosecutors and jurors now available, including the use of data visualization, data analysis at every investigatory stage, and other new techniques.

The Evolution of Pre-pay: Looking at what has and has NOT worked. Where do we go from here?
Presented by LexisNexis, an NHCAA Platinum Supporting member
Wednesday, 3:10 p.m. - 4:10 p.m.
Level II

Thomas M. Figurski, MBA, CFE, CPC
Manager, Special Investigations\Internal Audit, Gateway Health Plan

Richard Morino
Senior Solutions Executive, Health Care, LexisNexis

This session will examine where pre-pay fraud detection has fallen short in the past and how emerging technologies brighten the future for this often doubted capability. Define what pre-pay is and is not and understand how embracing this as a core part of any payment integrity program not only saves dollars but allows health plans to focus on their number one priority - members. We will also review a real-life case study highlighting the benefits of some of the newer pre-pay approaches.

Emerging FWA Issues and Trends in Medicare Part D
Presented by Xerox, an NHCAA Platinum Supporting member
Wednesday, 3:10 p.m. - 4:10 p.m.
Level II

Joshua Peters, PharmD, RPh
Pharmacy Claims Auditor, Xerox

Fraud, Waste, and Abuse (FWA) in healthcare potentially harms patients, costs billions of dollars, and is always changing. Specific trends may change, but their underlying patterns persist and exploit weak links in the overall healthcare system. Medicare Part D has been highlighted by Health and Human Services, Office of the Inspector General (HHS-OIG), the Department of Justice (DOJ), and the Centers for Medicare & Medicaid Services (CMS) as particularly vulnerable. Join members of the Audit & Compliance Solutions team at Xerox and their health plan client as they show how programs, geography and drugs may change, but incentives and disincentives drive the next emerging scheme. This discussion will present emerging patterns of behavior in pharmacy claims, the migration and perpetual nature of certain billing practices, and the incorporation of HHS-OIG, CMS and DOJ recommendations into practical analysis. The presenters will share expertise and knowledge gained through extensive data analysis and pharmacy onsite audits.

Interactive Lead Generation Workshop
Presented by General Dynamics Information Technology, an NHCAA Platinum Supporting member
Thursday, 8:15 a.m. - 9:30 a.m.
Level II

Jessica Gay, CPC
Investigator, General Dynamics IT

Erin Picton, AHFI
SIU Supervisor, General Dynamics IT

Attend an informative and interactive lead generation workshop with General Dynamics IT's Special Investigations Unit (SIU). Investigative staff will guide you through the identification, research, mining, data analytics, and presentation as well as case development. Investigators will demonstrate innovative and creative ways to illustrate findings that will streamline committee approvals and appeal to a variety of preferences. The sample leads will be specific to professional and pharmacy collusion and will be covered in a step-by-step process, outlining best practices for demonstrating findings.

Inpatient Authorizations: The Risk of Overpayment
Presented by CGI Federal, an NHCAA Platinum Supporting member
Thursday, 8:15 a.m. - 9:30 a.m.
Level II

Robert Haskey, MD, FACS
Executive Medical Director, CGI Federal

As a steward of limited healthcare dollars, health plans carefully manage medical loss ratios. An important component of that task involves administering inpatient service requests using efficient, front-end prior authorization systems. Healthcare payers are increasingly providing authorization for inpatient billing and reimbursement through Web-based, telephonic or fax-based processes. These systems are efficient and well-functioning but are dependent upon information communicated by facilities before services are rendered. Because demands on the healthcare system are numerous, fast-paced, and subject to veracity, this information can have omissions, misstatements, or factual errors. Is your organization detecting factual errors effectively? If not, a vulnerability exists that could lead to very substantial over-reimbursement for services rendered. Authorization of a more invasive surgical approach when, in reality, a less invasive procedure was accomplished but still reported as an "In-Patient", is just one example . Learn how specialized audit is able to find the variant claim.

Using Adaptive Predictive Analytics to Discover Facility Payment Schedule and Contract Issues
Presented by FICO, an NHCAA Platinum Supporting member
Thursday, 10:15 a.m. - 11:15 a.m.
Level II

Allyn Pon
Senior Product Manager, FICO

Most fraud detection schemes cover professional claims with a variety of methodologies for both rules based and advanced predictive analytics. However, facility expenditures are twice the amount of professional claims in the government sector, and about equal in dollars in the commercial market. Despite these large expenditures, scant attention has been devoted to facility fraud, waste and abuse analytics. The complexity of facility payment systems makes this a challenge for any analytic to detect issues that are actionable. This session is devoted to describing the unique challenges and results that fraud, waste and abuse analytics in the facility space have found. This session will cover how adaptive predictive analytics can discover numerous payment schedules and contractual issues that would fall under the radar using rules based analytics.

The Latest Trends in Waste and Abuse
Presented by McKesson Health Solutions, an NHCAA Platinum Supporting member
Thursday, 11:30 a.m. - 12:30 p.m.
Level II

Ali Russo
Director of Analytic Services, McKesson Health Solutions

Come hear the very latest billing trends across the country as found through unstructured, predictive analytics, and structured analysis of a paid claims dataset representing more than 75 million covered lives, updated through at least June of 2014, and equally representing four regions across the United States within Commercial, Medicaid and Medicare lines of business. The analysis has uncovered some surprising areas of over-billing such as unnecessarily high levels of service areas where there could be unwarranted increases in readmissions and interesting trends in length of stay for particular diagnoses in an inpatient setting. We will also cover other areas that you can look into when you get back to your office. Our experts will describe how these benchmark analytics can help to discover the causes of waste and abuse, from blatant up-coding to outdated or missing medical policies.

Dissecting Inpatient Rehabilitation Services
Presented by Health Care Excel, an NHCAA Premier Supporting member
Thursday, 2:00 p.m. - 3:00 p.m.
Level II

Timothy Burrell, MD, MBA
Medical Director, Health Care Excel

Inpatient Rehabilitation Facility (IRF) services are some of the most regulated in medicine and, perhaps because of this, are some of the least documentation and payment compliant. Since IRF services account for over $10 billion in payments per year with an average base rate of $15,000 per claim, these claims clearly justify payment integrity efforts to ensure proper payment by public and private payers. This workshop will instruct investigators and general clinicians alike in the analysis of IRF claims for medical necessity and documentation compliance. Starting with the Medicare Section 110 requirements and ending with potential investigation opportunities, this fast-paced workshop will broaden the attendee's ability to comprehend and investigate technical aspects of inpatient rehabilitation claims.

Uncovering Hidden Cosmetic Procedures
Presented by Healthcare Fraud Shield, an NHCAA Premier Supporting member
Thursday, 2:00 p.m. - 3:00 p.m.
Level II

Tony Rademeyer, MBA
EVP, Sales, Healthcare Fraud Shield

Kate Shaker, RN, BSN, CPC, CPC-H, AHFI
Consultant, Healthcare Fraud Shield

Karen Weintraub, MA, AHFI, CPC-P, CPMA
Executive Vice President, SIU, Healthcare Fraud Shield

Payers may be unknowingly reimbursing providers/members for non-covered cosmetic procedures. Because these services are being disguised and billed with commonly covered procedure codes, they may go undetected. The faculty will discuss new schemes including cosmetic toe-shortening procedures, Botox injections, erectile dysfunction injection therapy and more. They will demonstrate how to data mine, detect these schemes and investigative steps.

Start Thursday Morning with a Hot Breakfast Coupled with Education by some of today's leading anti-fraud technology solutions. Thursday, 7:00 a.m. - 8:00 a.m.

 

How Practices with Certified Compliance Programs Can Reduce SIU Workloads
Presented by AAPC, an NHCAA Premier Supporting member
Level II

Barry Johnson
President Enterprise Solutions, AAPC

Jeff Young
Product Executive, AAPC

The prevention of fraud, waste and abuse begins at the provider office or facility with the development and management of a comprehensive compliance program. In the late nineties, the OIG published recommended guidelines for an effective and comprehensive compliance program, which addresses seven key components. These components primarily focus on the submission of appropriate claims to ensure that services billed are reasonable as well as necessary for the care of the patient. This session will focus on how a well-established compliance program can improve the accuracy of claims prior to submission, and act as a mechanism for preventing fraud waste and abuse. Specifically, the concept of certifying provider practices and organizations will be presented, and how this "Seal of Approval" affords payors the benefit of knowing that certified practices are compliant in their billing, reimbursement, documentation protocols, and ongoing oversight of their personnel.


New Threats. New Thinking.
Presented by IBM, an NHCAA Premier Supporting member
Level II

Jonathan Muise
IBM, US Counter Fraud Solutions Executive

Fraud, abuse and improper payments are on the rise, driven by opportunistic individuals, providers, and organized crime rings. Wanting to reduce the frequency and volume of improper payments, a holistic approach is required that can both deter and intercept suspicious submissions, while in parallel detect, investigate and build compelling cases for prosecution, recovery or denial of payment. IBM Smarter counter fraud approach delivers this, with advanced analytics and rich investigative analysis throughout the entire counter fraud process, enabling healthcare organizations to lower fraud losses, reduce operating costs, while delivering superior service to valued customers and providers. Come learn about this new solution and the industry rich services that our experts can provide.


Antiretroviral Therapy Abuse and Overutilization
Presented by Palantir Technologies, an NHCAA Premier Supporting member
Level II

Patrick Tardif
Forward Deployed Engineer, Palantir Technologies

Antiretroviral therapy (ART) represents the accepted conventional treatment for managing HIV/AIDS. ART usually involves a combination of at least three different types of antiretroviral drug classes acting on different stages of the HIV life cycle. These can be administered in many different combinations either separately or as combination drugs. These drugs are also extremely expensive, resulting in ripe opportunity for overutilization and street diversion. However, given the complexity of ART, abuse can often go undetected by standard algorithms. This comes at great cost given that drug regimens per patient can exceed several thousand dollars per month. In order to combat this, a deeper understanding of the required constituents of appropriate ART is required. These involve checking for redundant cocktail drugs, even when spread across different dates of service as well as different prescribers and pharmacies. Precise algorithms to achieve savings will be presented along with stories from past investigations on potential variations of ART schemes.


Increasing Investigative ROI through the Project Model Approach
Presented by SAS, an NHCAA Premier Supporting member
Level II

Ricky Sluder, CFE, CFLMS, CFCE, CBFE
Senior Solutions Architect, Security Intelligence Practice, SAS

In a typical investigation, each lead requires significant work to validate a credible allegation of fraud, but typically produces little return on investment (ROI). In addition to lead identification, internal and external political pressure, and the way cases are assigned can also negatively impact ROI. Inadequate resourcing and overburdened investigative units lead to an underutilization of the investigators knowledge, skills and abilities. So, what if you could achieve more with less? If your department was to analyze how workload was assigned, would you know the cost to pursue each case, as compared to the savings you generated? Are you expected to do the same thing, but achieve better results? If you could manage 100 investigations simultaneously, while doubling your ROI, would you? Consider the Project Model approach, which defies traditional investigative plans of pursuing single investigations from beginning to end. It also omits investigating complaints as a single source of wrong-doing on any one provider. This presentation will explore how this approach works by identifying "Common Denominators"TM for several providers within the same specialty area. The presentation will define the benefits and provide real life examples (and ROI) of Project Model success.


Increase SIU Effectiveness with a Flexible Workflow Technology
Presented by SCIO Health Analytics, an NHCAA Premier Supporting Member
Level II

Rodger Smith, JD
SVP Payment Integrity Solutions, SCIO Health Analytics

Krista Kottapalli
Chief Sales and Marketing Officer

Sumant Rao
Senior Vice President, Technology, SCIO Health Analytics

Teams focused on payment integrity and fraud, waste & abuse must perform various important tasks effectively to succeed. Functions vital to success include: sifting through large amounts of data to find the best claims and providers to address, managing large workflows, caseloads, and claims for review and having insightful visibility into status, flow and processes to effectively allocate scarce resources effectively. Despite this, many plans have outdated and inflexible platforms, or work on Excel spreadsheets. This can cost hours, if not days in lost productivity, and mean inefficient allocation of valuable personnel. SCIO Health Analytics now offers clients access to the same cutting-edge technology SCIO uses internally to address these matters - the proprietary platform SCIOMine. This presentation will highlight the flexibility of SCIOMine, and give real life examples of how it works, and time and resources that can be saved.