Conference Sessions

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Clinical Issues for the Health Care Fraud Investigator
Behavioral Health Fraud Schemes
Detecting and Investigating Dental Fraud
Fraud Schemes and Investigative Skills
Fraud in Medicaid Program
Pharmacy & Part D Fraud
Legal, Management & Compliance Issues
Transformation of Health Care
Disability, Life, Long-Term Care & Workers' Compensation
Anti-Fraud Technology Solutions

View ATC Schedule-at-a-Glance

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.

 

Clinical Issues for the Health Care Fraud Investigator

 

Testosterone Therapy
Wednesday, 9:15 a.m. - 10:15 a.m.
Level II

Linda Cote, AHFI
Senior Investigator, Aetna

Gordon Grundy, MD
SIU Medical Director, Aetna

The presenters will discuss in detail the clinical indications for testosterone therapy, and how the recent publicity regarding this treatment as an anti-aging therapy has led to widespread abuse of this treatment. Faculty will examine how the lack of controls to monitor potential life-threatening side effects makes this abuse even more dangerous and a quality of care concern for patients. Billing patterns and ways to identify suspect providers will be demonstrated. A case history will be covered which will include how this problem was discovered, the investigative steps taken, pitfalls encountered while investigating, results achieved, and tips to mitigate loss.

Clinical Trial Billing Compliance
Wednesday, 2:15 p.m. - 3:15 p.m.
Level II

Cindy Parman CPC, CPC-H, RCC
Principal, Coding Strategies Inc

Two modifiers, one diagnosis code and a requirement to supply the clinical trial number make coding services associated with clinical trials a challenge. Insurers are sometimes required to reimburse for routine services, but some payors may not have to pay for anything related to a clinical trial. The Affordable Care Act has impacted trial reimbursement, but the extent of payment may still be in question. This session will review definitions of routine and investigational services, explore public audits and investigations involving clinical trials and provide examples of correct and incorrect modifier and diagnosis code reporting.

Electrodiagnostic Medicine
Wednesday, 3:25 p.m. - 4:25 p.m.
Level II

Peter Grant, MD, PC
Medical Doctor, Past President of the American Association of Neuromuscular & Electrodiagnostic
Medicine (AANEM)

Faculty will provide an overview of EDX fraud and abuse in the US and then discuss the common types of EDX fraud and abuse including mobile diagnostic labs, hand-held devices, QST devices and other inappropriate EDX practices or schemes. The presenter will demonstrate what constitutes quality EDX studies and what means are available to substantiate appropriate studies. Attendees will walk away with resources to better recognize and understand the different types of EDX fraud and abuse, and ideas on ways to combat EDX fraud and abuse.

Endoscopic Sinus Surgery
Thursday, 8:15 a.m. - 9:30 a.m.
Level III

Fred Holt, MD, JD, AHFI
Managing Member, Medical Affairs Partners, LLC

Leland Garrett, MD
Medical Director for Special Investigations, Blue Cross Blue Shield of North Carolina

The popularity of endoscopic sinus surgery has soared among Otolaryngologists since its introduction in the 1980s. Now balloon dilatation of the sinus openings has made richly-reimbursable sinus operations possible in the office setting. Abuse of these operations has proliferated. This session will teach the participants what these procedures are, why they are so popular, and how they are causing payors unnecessary loss. Faculty will show how one plan recognized the problem and brought it under control though the use of the adaptation of a strong evidence base into the plan's own rule set with the input and buy-in from the local ENT physician community. Attendees will leave the class armed with a game plan to see whether their plans are impacted and, if so, how to gain control of the problem.

Urine Drug Screens: CPT Coding Update
Thursday, 10:15 a.m. - 11:15 a.m.
Level II

Pricilla Alfaro, MD
Medical Director, Anthem, Inc.

Janet Bonham, AHFI
Senior Investigator, Anthem, Inc.

Carl Reinhardt, AHFI, CPC
Manager, Anthem Medicaid Special Investigations Unit, Anthem, Inc.

This workshop will look at the morphing of urine drug screens from 80101/80104 to the quantitative testing of the urine specimen. Faculty will examine the specific level of test and the required laboratory equipment and reagents required to perform that level of testing. The presenters will explain and define the terms used in the laboratory process and their significance to the investigation, and explain the 2014 & 2015 CPT coding for UDT and the significance of the changes. The session uses current case examples, investigative steps, and shared experiences so that an experience investigator can replicate the process in their own SIU.

Chiropractic Medicine
Thursday, 11:30 a.m. - 12:30 p.m.
Level III

Daniel Bowerman, DC, AHFI, CPC
Consultant

Chiropractic anti-fraud expert provides a look at the chiropractic office visit and how to identify medically unlikely occurrences from the medical records and claims. Faculty will examine fraud schemes that keep him up at night, and demonstrate ways to uncover the behavior. Attendees will walk away with a better understanding of what to look for, what to request and what to ask when investigating a chiropractic case.

Genetic and Biomarker Testing
Thursday, 2:00 p.m. - 3:15 p.m. | Friday, 9:45 a.m. - 11:00 a.m.
Level III

Kristine Bordenave, MD, FACP
Lead Medical Director, Special Investigations Unit & Provider Payment and Integrity, Humana

Ksenia Coble, RN, CPC
Clinical Auditor, Humana

Expert faculty will explain the current genetic and biomarker testing environment and its current sales appeal in the US. The presenters will describe the methodologies used to perform the various tests and explain the associated coding. Through examples, faculty will demonstrate the identification of schemes used to obtain inappropriate maximum payment by payer systems and provide the existing and proposed criteria defining appropriate utilization and billing for this testing.

Behavioral Health Fraud Schemes

 

Applied Behavior Analysis (ABA) Services
Wednesday, 11:00 a.m. - 12:00 p.m.
Level II

Margaret Payne
Manager, Program Integrity, Humana

The session begins with an overview of the ABA benefit and the services included in the benefit. Through samples of case investigations faculty will demonstrate a number of fraudulent billing schemes including misrepresentation of both services and providers, excessive units billed and fabricated records. Attendees will walk away with examples of multiple schemes and how to data mine to uncover suspect behavior.

Community Mental Health Centers: A Case StudyLEL Path
Thursday, 8:15 a.m. - 9:30 a.m.
Level II

Thomas Daly
Special Agent, U.S. Department of Justice, Federal Bureau of Investigation

Ritchard Houdashelt
Special Agent, U.S. Department of Health and Human Services, OIG-OI

Federal agents present a recent case study of one of the largest health care fraud schemes to date involving three Community Mental Health Centers in Louisiana and Texas which resulted in seventeen criminal convictions and restitution orders in excess of $43 million. These three facilities combined billed Medicare more than $258 million were paid over $51 million over a seven year period. Faculty will provide tips on various investigative techniques they used, as well as road blocks they encountered when investigating a behavioral health care.

Mental Health Services and the ACA
Thursday, 11:30 a.m. - 12:30 p.m.
Level III

James Slayton, MD
National Medical Director for Outpatient Services, OptumHealth Behavioral Solutions

Elizabeth Martin, JD
VP, Program & Network Integrity, Optum

FWA detection and analysis has taken on new importance post ACA as health plans are now managing expanded public sector population behavioral health benefits. The new benefits expansion has given rise to 'unconventional' behavioral health outpatient services. Faculty will illustrate the opportunities in this area with specific focus on psychosocial rehabilitation services. Case examples, detection techniques and 'lessons learned' will be shared with workshop participants.

Group Therapy
Friday, 9:45 a.m. - 11:00 a.m.
Level II

Gary M. Henschen, MD
Chief Medical Officer, Behavioral Health, Magellan Health Services, Inc.

Faculty examines the group therapy visit, with a focus on the behavioral health benefit, correct coding and best clinical practices. Common schemes will be discussed with the focus on detection and prevention of abusive patterns of billing.

Detecting and Investigating Dental Fraud

 

Foreign Dental Claims & Schemes
Wednesday, 9:15 a.m. - 10:15 a.m.
Level II

Joaquin Basauri
Senior Investigator, Kaiser Permanente

Julie Heit
Dental Hygienist, Manager - Ancillary Utilisation Review, Bupa Australia

Dental fraud is not unique to the U.S., and cross-border fraud schemes are becoming increasingly more prevalent. Investigators will share first hand experiences with dental fraud schemes perpetrated in Australia and in Mexico and focus on the types of schemes occurring and strategies for detection and prevention.

Dental Coding Schemes AHFI Path
Wednesday, 11:00 a.m. - 12:00 p.m.
Level II

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

Suzette Long, RDH, AHFI
Senior Consulting Manager, Truven Health Analytics

Mary Morales, MHSA, RDH
Investigator, Dental Special Investigations, Anthem, Inc.

Trish M. Shifflett, RDH, AHFI
Clinical Fraud Analyst, Delta Dental of Virginia

A panel of dental hygenist fraud investigators examines a variety CDT and CPT dental coding schemes and provide tips for data mining to reduce exposure. Hear schemes impacting both private insurance and government programs, and learn to identify the red flags in claims and dental record.

Demystifying Oral and Maxillofacial Surgery: Extractions, Impactions, Anesthesia, Sleep Apnea Appliances, and Billing
Wednesday, 3:25 p.m. - 4:25 p.m.
Level III

David Rubin, DDS
Oral Maxillofacial Surgeon, HMS

Many dental providers - from general dentists to oral and maxillofacial surgeons - are up coding simple extractions to surgical extractions. Providers are also up coding impactions from soft tissue to complete bony extractions. This presentation will explore the differences between all of the extractions codes. Furthermore, dental providers can misrepresent which anesthesia technique they administer. Presentation attendees will learn how to dissect the dental chart to learn the techniques used and a reasonable amount of time for each procedure. Since sleep apnea is a current buzzword for dental providers, they often try to bill medical insurance for sleep apnea appliances, as the reimbursements are higher on the medical side. Presentation attendees will learn what a sleep apnea appliance is - not simply a device to stop bruxism - and when it is appropriate to bill medical insurance.

Dental Fraud Schemes in the Commercial & Public Sector
Thursday, 8:15 a.m. - 9:30 a.m.
Level II

Richard Celko, DMD, MBA, AHFI
Regional Dental Director, UPMC Health Plan

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

Dental fraud, waste and abuse schemes in both the commercial and public sectors appear with many similarities, however investigators need to be aware of the differences in plan design in order to better detect schemes which are predominantly focused to each unique sector. This presentation will review the more common schemes in dental fraud and discuss how they would appear to the investigator in the commercial and public sectors, and what particular investigative skills may be required as seen through the experiences of both commercial and government sector dental directors.

Dental Directors' Quick Hits Panel
Thursday, 2:00 p.m. - 3:15 p.m.
Level II

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

George Koumaras, DDS, AHFI
Dental Analytics Director, Anthem, 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.

Fraud Schemes and Investigative Skills

 

Diabetic Neuropathy Clinics LEL Path
Wednesday, 9:15 a.m - 10:15 a.m.
Level II

Jennifer Schlinz
Special Agent, U.S. Department of Justice, Federal Bureau of Investigation

Cindi Woolery
Assistant United States Attorney, United States Attorney's Office for the Western District of Missouri

The presenters will review and discuss the latest diabetic neuropathy clinics (aka chiropractic offices disguised as multi-disciplinary clinics) and their treatments. These neuropathy treatments which are advertised to cure neuropathy are considered investigational by most insurance payers and CMS. The payments for these types of procedures are being masked as therapy along with injections of anesthetics into patient's ankles. During the presentation, the participants will learn about nerve conduction studies, nerve block injections, physical therapy, pneumatic chair therapy, balance therapy, electrical stimulation and ultrasound needle guidance. The affiliated procedure codes will be provided so that the participants can return home and data mine for similar schemes.

Freestanding Emergency Centers
Wednesday, 11:15 a.m. - 12:15 p.m.
Level II

Kenneth Cole, AHFI, CFE, CPC
Supervisory Investigator, Healthcare Fraud Shield

In recent years, hospitals have moved some traditionally hospital-based healthcare services out of the hospitals to external entities. One of these external entities are freestanding emergency centers (FSEC). Similarly with existing urgent care centers and ambulatory surgical centers, detecting and addressing FWA concerns from FSECs may present a new and unique challenge to the SIU. These challenges include identifying differences in traditional ER billing patterns and differences in federal and state regulation and oversight for these facilities. This session explores these challenges and presents suggestions to identify potentially aberrant FSEC billers. Once identified, faculty will demonstrate the application of the appropriate techniques and resources to questionable FSEC to insure an efficient investigation with a positive return on investment.

Medical Identity Theft Panel LEL Path
Wednesday, 2:15 p.m. - 3:15 p.m.
Level II

Jean Stone
Program Integrity Senior Specialist, U.S. Department of Health and Human Services, CMS

Joseph Popillo, AHFI, CPCO, CPC-A
Director, Corporate Compliance Special Investigations Unit, Health First Inc.

Jutta Williams, CISSP, CIPP, CISA
VP, Chief Compliance Officer, Chief Information Assurance Officer, Health First Inc

As the health care industry continues to change, identity theft serves as the root to many channels used in perpetuating health care fraud. Faculty from the private and public sectors will provide examples of strategies at work to battle the theft of medical identities. Hear initiatives that the Medicare program has implemented to safeguard against ID theft. From the private sector, learn how an Integrated Delivery Network (IDN) leverages privacy and FWA resources to battle theft of services in its ERs.

Forensic Accounting in Health Care Fraud Investigations
Wednesday, 2:15 p.m. - 3:15 p.m.
Level II

Emily Foss, MBA, MAcc, CFE
Humana, Special Investigator, Special Investigations Unit

Health care fraud is a form of white collar crime that is on the rise and costing billions of dollars in the United States. Forensic Accountants are trained to follow money and apply dollars to motive. Typically, there is only one motive in healthcare fraud and that motive is to increase a bank account. The fraud may be perpetuated individually or as a conspiracy with many parties involved. The Forensic Accountant is able to evaluate healthcare fraud from a different perspective, which attaches the dollars to the schemes being perpetuated. The presenter will discuss investigative strategies that assist with "following the money" and making sense of the dollars associated with various schemes. Schemes to defraud versus policy/plan violations will be discussed. A discussion of what constitutes criminal activity will focus on when a provider knowingly and willingly performs an act to increase their bank account.

2015 Investigation of the Year LEL Path
Wednesday, 3:25 p.m. - 4:25 p.m.
Level II

Welcome the recipients of NHCAA's 2015 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.

Home Health Care LEL Path
Thursday, 8:15 a.m. - 9:30 a.m.
Level II

Lisa Garcia, RN, COS-C
Nurse Investigator/Law Enforcement Liaison, Health Integrity, LLC

James Hargrove
Vice President of Operations, Fee For Service, Health Integrity, LLC

Stephen Ward, AHFI, CFE
Project Director/Law Enforcement Liaison, Health Integrity, LLC

The presenters will discuss in detail the latest changes in home health regulations including but not limited to what qualifies a patient for home health, who should be ordering the home health and who can sign a face to face encounter home health form. The discussion will include the latest trends and schemes identified that affect Medicare reimbursement on a daily basis. These trends and schemes include, but are not limited to the forging of the physician signature as well as the signing of documents by a physician without establishing a patient-physician relationship as required by Medicare. Because of the nature of the honor based claims processing system Medicare has in place, the claims, when filed are paid and only reviewed if flagged by an edit or a payor. The discussion will include the relevant facts of an actual prosecuted case that will support the presentation and demonstrate the fraudulent behavior.

Conducting a Lab Audit from Chart to Bill AHFI Path
Thursday, 8:15 a.m. - 9:30 a.m.
Level II

Melissa Scott, CHC, CPC
President, ClinLab Consultants

Expert faculty will demonstrate the steps of a laboratory audit, and focus on the red flags that can be identified throughout the process. The session will focus on continuity from order to result to billing - the synchronization required for a valid claim. At the conclusion of the session attendees will understanding the distinctions for physician office labs, freestanding labs, and billing for referred tests.

Oncology Services Fraud Case Study LEL Path
Thursday, 8:15 a.m. - 9:30 a.m.
Friday, 9:45 a.m. - 11:00 a.m.
Level II

Catherine Dick
Assistant United States Attorney, U.S. Department of Justice

Bryan Drake
Special Agent, U.S. Department of Justice, Federal Bureau of Investigation

The presentation will detail a fast-paced health care fraud investigation into Dr. Farid Fata, an oncologist arrested in August 2013 on charges of health care fraud (including practices that resulted in patient harm), kickbacks, and money laundering. Presenters will discuss challenges arising from several unique aspects of the case, including: scale (Fata's practice billed $400 million in approximately six years), speed (Fata was arrested just four days after the FBI learned of the allegations), potential disruption of critical patient care, and national media attention. Presenters will outline, in detail, the fraud executed by Dr. Fata that went unchecked for years and the approach taken by investigators to gather an immense amount of information in a short time to secure indictments and eventually a guilty plea.

SIRIS Investigation of the Year
Thursday, 10:15 a.m. - 11:15 a.m.
Level II

Hear how a SIRIS lead led to an award winning investigation. NHCAA unveils a new award for investigations that were either discovered or significantly enhanced by a SIRIS lead. Attendees will follow the investigative twists and turns and best practices for building a successful case.

Fraud Analytic Techniques: Simple Techniques to Uncover Complex Schemes AHFI Path
Thursday, 11:30 a.m. - 12:30 p.m.
Level II

James McCall, AHFI
Director, Fraud Analytics, Emdeon

The presenter will first introduce a suspect behavior classification model that breaks fraud risk into four easy to understand groups, frequency, density, intensity and velocity. Understanding high risk behaviors in this context, allows for easy transition of detection methodologies. Once the model is understood, regardless of the specific schemes that occur (which codes, etc) having models in place to uncover any of these 4 behaviors, will detect the abnormal behaviors, and bring them to the attention of the reviewer for additional investigation. The presenter will then discuss specific techniques using simple tools such as Excel and/or free downloads which can be used to uncover these behaviors. Detailed materials will be prepared and provided to allow for simple application of these techniques when the participants return to their desks in the office. Throughout the presentation real-life examples will be used to highlight how these techniques can be used successfully.

Ambulance Fraud LEL Path
Thursday 2:00 p.m. - 3:15 p.m.
Level II

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

Jeremy Thornton
Special Agent, U.S. Department of Health and 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 we 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. We will also discuss effective techniques used to investigate ambulance fraud cases. These points will be supplemented with real case examples.

Clinical Laboratory Case Study
Thursday, 2:00 p.m. - 3:15 p.m.
Level II

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

John Croes
Special Agent, U.S. Department of Health and Human Services, OIG-OI

The presenters will discuss schemes used to defraud Medicare and private insurances in the area of clinical laboratories and ways to investigate and prosecute those schemes. Discussions will involve ways that CPT Codes are manipulated and means to conceal bribe and kickback payments. There are many methods which can be used to investigate clinical laboratory frauds and bribes/kickbacks and the presenters will explain some of the successful tactics they have used. During the presentation, a current investigation will be used as a case study to discuss: detection of fraudulent activities; ways to identify practitioners and clinical laboratories involved in fraud and bribes/kickbacks; the use of claims pattern analysis and financial record review; and the use of law enforcement techniques. Attendees will receive information that can improve their investigative skills and increase the rate of success when investigating and prosecuting clinical laboratory cases.

Prosecuting Hospital Fraud: a Case Study LEL Path
Thursday, 2:00 p.m. - 3:15 p.m.
Level II

Jack Geren, CFS
Special Agent, U.S. Department of Health and Human Services, Office of the Inspector General, OI

Nathaniel Kummerfeld, JD
Assistant U.S. Attorney, Healthcare Fraud Coordinator, U.S. Attorney's Office, Eastern District of Texas

Through the experiences of a team that successfully prosecuted a hospital chain owner for his role in up-coding DRG payments across multiple hospitals, participants will not only be taught the techniques and strategies used throughout the trial, but also the various pitfalls avoided and overcame in route throughout the investigation and prosecution. Participants will be shown useful investigative techniques and informed of strategies used to make critical decisions. Participants' learning will be enforced through the presentation of two cutting-edge cases that received national attention.

Operation Cinco Castillos: New Physical Therapy and J Code Schemes Targeting Private Insurance Carriers
Thursday, 3:30 p.m. - 5:00 p.m.
Level II

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

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

Christine Ramirez
Special Agent, U.S. Department of Health and Human Services, OIG-OI

This case study examines the investigation of a scheme to defraud privately insured health care plans, chiefly self-insured employers, who offered Administrative Services Only (ASO) insurance plans to their employees and out of state host plans. The discussion will focus on a group that recruited massage therapists to open physical therapy clinics. These individuals utilized medical director staffing companies to obtain and misappropriate the names and licensing information for numerous physicians. This information was then used to submit false and fraudulent physical therapy and injection claims to the private insurance plans. Owners paid kickbacks to recruiters to provide patients who would sign documents falsely and fraudulently representing that they had received medical services when, in fact, they had not received medical services. Owners also recruited uninsured individuals to enroll in private health insurance plans and would pay the monthly premium and additional kickbacks in exchange for billing under the complicit patients' names. In the span of one and one-half years, private insurance plans were billed over $130 million in false and fraudulent claims. The group then used the proceeds of the fraud scheme to purchase commercial real estate properties to house their new clinics and further the scheme. A s a result of this case study, participants will learn: new schemes targeting private insurance host and ASO plans; new JCodes used by fraudulent Physical Therapy clinics to defraud the insurers; new variations on kickback schemes; and methods by which private insurers may refer and charge private insurance cases to federal investigators under the federal health care fraud statutes.

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 and Human Services, OIG-OI

The session will examine 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.

Fraud in Medicaid Program

 

Investigating Medicaid Fraud: The Health Plan Perspective
Wednesday, 9:15 a.m. - 10:15 a.m.
Level II

Cherie Ottochian, CPC
Senior Investigator, Aetna

Janine Kumanchik, AHFI, HCAFA
Manager, SIU, CareSource Management Group

Tina Sinclair, CPC, AHFI
Senior Investigator, Anthem, Inc.

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 investigating fraud in the Medicaid populations they serve. Schemes will be discussed in terms of specific codes, data mining tips, and investigative examples to promote best practices when investigating fraud in the Medicaid program.

An Ambulance Fraud Case Study
Wednesday, 11:00 a.m. - 12:00 p.m.
Level II

Michael Wysocki, CPA
Senior Investigator, Anthem, Inc.

Stormy Kelly
Investigative Manager, Medicaid Fraud Control Unit of Texas, OAG

The presentation will focus on a multifaceted investigation involving ambulance service providers and habilitation therapy centers. Investigators uncovered the scheme where 40 ambulance companies in the Houston Texas area that were transporting Medicaid recipients to group habilitation therapy in transportation vans but billing for ambulance transportation. The case study will focus on the investigative techniques used to uncover the scheme and how to identify these patterns in your claims data.

Home Health: Operation Capitol Ills LEL Path
Wednesday, 2:15 p.m. - 3:15 p.m.
Level II

Brent Wolfingbarger
Deputy Director, Medicaid Fraud Control Unit of DC, Office of DC Inspector General

Faculty detail a multi-agency investigative effort and the tools used in order to bring a network of recruiters, personal care assistants and home health agencies to justice. Tools used included subpoenas, undercover operations, detailed document analysis and wiretaps, and the presenters will provide their "Monday morning quarterback" notes on what was effective and what they would have approached differently.

Using Prescription Drug Monitoring Program Data to Identify Fraud Home Health: Operation Capitol Ills LEL Path
Thursday, 11:30 a.m. - 12:30 p.m.
Level II

Judith Coffey
Supervisor Deputy Attorney General, Medicaid Fraud Control Unit, Office of the Indiana Attorney General

Taya Fernandes
Drug Diversion Analyst, Indiana Office of the Attorney General

Making a prosecutable case against a pill-mill operator and its employees can be challenging. Because these cases always involve a practitioner who has legal authority to prescribe controlled substances, a considerable amount of evidence is required to prove that the prescribing was outside the scope of accepted medical practice and without a legitimate medical purpose. With the advent of prescription monitoring programs there is an opportunity to quickly identify high-volume prescribers and perform an analysis to determine whether they were overprescribing and if so, to what extent. In this session attendees will learn to identify dangerous prescribing trends, identify the lethal combinations and quantities, and use the morphine equivalency tables. Attendees will have a chance to test their knowledge through participation in case examples.

Hospice Storm Project: Identifying Hospice Fraud in Medicaid LEL Path
Thursday, 2:00 p.m. - 3:15 p.m.
Friday, 9:45 a.m. - 11:00 a.m.

Chris Covington
Assistant Special Agent in Charge, U.S. Department of Health and Human Services, Office of the Inspector General

David Delgado
Criminal Investigator, Medicaid Fraud Control Unit of Mississippi, OAG

The presentation will focus on the epidemic of hospice fraud in Mississippi with an emphasis on the 'Hospice Storm' project which seeks to identify, investigate and prosecute fraudulent hospice providers. The workshop will begin with an overview of hospice fraud in Mississippi which often originates with door-to-door solicitations by patient recruiters and collaboration by 'medical directors' who are paid by hospices to falsely certify that patients are terminally ill. There will be a general discussion of techniques to identify potentially fraudulent hospices using data analytics such as finding patients who have been on the benefit for extended periods of time. The remainder of the presentation will be a case summary of the successful investigation of Angelic Hospice. The owner of this hospice pled guilty to an $8 million fraud and was sentenced to nearly 6 years in prison in December 2014.

Pharmacy & Part D Fraud

 

Emerging Threats: Pharmaceuticals LEL Path
Wednesday, 9:15 a.m. - 10:15 a.m.
Level II

Michael Cohen, DHSc, JD, PA-C
Inspector, U.S. Department of Health and Human Services, OIG-Ol

Shimon Richmond
Assistant Special Agent in Charge, Investigative Branch, U.S. Department of Health and Human Services, OIG-OI

Join to seasoned OIG agents as they examine today's emerging and newly approved drugs and how they may be the focus of tomorrow's investigations. Faculty will explore the paradigm shift to non-controlled drug diversion and look closely and recently approved orphan drugs, the potential off-label uses of FDA approved pharmaceuticals and the newest high dollar, high value additions to the market.

Compounding Case Study LEL Path
Wednesday, 11:00 a.m. - 12:00 p.m.
Level II

James Boazzo
Special Agent, U.S. Department of Justice, Federal Bureau of Investigation

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

The presentation will focus on the Medicare Part D pharmacy benefit with respect to compounding prescriptions. The presentation will explore the Part D payment system for compounds, how providers can circumvent the current edits in place and the schemes involved with an investigation that led to the arrest and successful prosecution of a compounding pharmacy in New Jersey.

Counterfeit Pharmaceuticals
Wednesday, 3:25 p.m. - 4:25 p.m.
Level II

Shane Tiernan, AHFI
Associate Director, Purdue Pharma LP

Counterfeit medicines are found everywhere in the world. They range from random mixtures of harmful toxic substances to inactive, ineffective preparations. Some look so similar to the genuine product that they deceive health professionals as well as patients. In this presentation attendees will learn current global trends involving the counterfeit pharmaceuticals supply chain and the impact on the U.S. health care system. Faculty ill provide information on schemes to obtain these counterfeit drugs and resources available to the investigator combat this problem.

Marketing Schemes: Compounding Pharmacies LEL Path
Thursday, 10:15 a.m. - 11:15 a.m.
Level II

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

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

This workshop will address a serious trend emerging in the area of compounding pharmacies - namely the substantial increase in prescriptions for so-called pain and scar creams to Medicare, Medicaid, Tricare, and private insurance patients when the patients have not been seen by the providing physician/ARNP but have rather been 'cold-called' by a third-party marketing firm that links the patient with a pre-selected provider. The workshop will explore how marketing firms pay kickbacks to recruiters and how to develop a criminal case implicating the Anti-Kickback and HCF statutes.

Compromised Clinics and their impact on Medicare Part A, B, and D Fraud LEL Path
Thursday, 11:30 p.m. - 12:30 p.m.
Level II

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

Roger Cruz
Assistant United States Attorney, U.S. Attorney's Office, Southern District of Florida

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

Faculty will describe a large scale fraud scheme involving multiple interrelated prosecuted cases which are linked to over $40 million dollars in Part D fraud and tens of millions of dollars in Part A and B Fraud.. The presentation begins with case studies of two Miami clinics whose employees and owners were stealing prescriptions from two of the highest prescribing part D providers in the nation. The presentation will explain how these two clinics enabled over 40 suspect pharmacies and home health agencies to bilk millions of additional dollars from the Medicare Part, A, B, and D programs. The presenters will explain several of the investigative techniques utilized to uncover, investigate, and link this massive fraud ring. The presenters will discuss the key players involved in the schemes and some of the unique aspects of the cases such as undercover operations, fugitive apprehensions, drug diversion, data analysis links. The presenters will explain the roles of law enforcement and other related health care fraud investigative entities involved in these cases. Finally the presenters will highlight various recurring fraud trends relevant to the case studies and how to reduce the chances of this type of criminal health care fraud from being committed in the future.

Legal, Management & Compliance Issues

 

DOJ Update LEL Path
Wednesday, 9:15 a.m. - 10:15 a.m.
Level II

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

Faculty will discuss DOJ's fraud fighting initiatives and successes, and how to effectively collect and demonstrate evidence to assist in successful prosecutions.

Medicare Risk Adjustment Fraud Mgmt Path
Wednesday, 9:15 a.m. - 10:15 a.m.
Level III

Sharon Houlihan RN, CPC, CMAS
Manager Risk Adjustment Integrity Unit, Humana

Tammy Jones, RN, CPC
Triage Manager - Risk Adjustment Integrity Unit, Humana

Risk Adjustment fraud schemes are no longer just about selecting and enrolling healthy members (false enrollment schemes). False documentation practices can artificially inflate risk scores creating a different view of risk adjustment fraud schemes. The fraudulent practices may impact Medicare, Medicaid, and Commercial lines of business. Because of this deviation from what is known to be typical, the presenters will explain this at a deeper level so participants can walk away with an overall increased knowledge base regarding risk adjustment fraud. The presenters will explain what risk adjustment is from a clinical and payment perspective. This will include discussion on diagnosis coding and hierarchical condition categories (HCC's) that drive the premium payments. The different HCC models that can be used will also be discussed. This information lays the foundation to understand the complexity of risk adjustment fraud schemes. The presenters will describe how frauds are being perpetrated. These are not simply upcoding of a condition but complex schemes that require analytical evaluation of coding practices and also include financial and medical record analysis. To further enhance comprehension of these schemes, the presenters will then walk through an actual case. Time will be allotted at the end of the presentation for questions.

CMS Program Integrity Update
Wednesday, 2:15 p.m. - 3:15 p.m.
Level II

Jonathan Morse
Deputy Center Director, Center for Program Integrity, U.S. Department of Health and Human Services, CMS

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

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

Brian Flood, JD, AHFI
Partner, Husch Blackwell LLP

Faculty will explore the most important emerging anti-fraud legal and regulatory developments including recent state and federal court decisions, federal regulatory actions and interesting legislative initiatives.

Prosecuting Reverse False Claims Mgmt PathLEL Path
Thursday, 10:15 a.m. - 11:15 a.m.
Level II

Sam Sheldon, JD
Partner,Quinn Emanuel Urquhart & Sullivan LLP

Reuben Guttman
Director, Grant & Eisenhofer

Chris Haney, CPA, CFE
Director, Duff & Phelps

Faculty will explain the current climate for prosecuting Reverse False Claims, identify investigative techniques for identifying and resolving potential reverse false claims and examine key risk areas for reverse false claims and the roles of potential whistleblowers including employees and trusted advisors. The panel will discuss recent cases including Continuum Health, one of the first-ever reverse false claims act cases, and highlight the components of the alleged fraud. In conclusion, the panel will discuss the effect of Medicare delay in implementing final regulatory guidance regarding the 60-day rule.

 

Transformation of Health Care

 

NCCI Edits Mgmt Path
Wednesday, 11:00 a.m. - 12:00 p.m.
Level II

Daniel Duval, MD
Chief Medical Officer, Center for Program Integrity
Deputy Center Director, Center for Program Integrity, U.S. Department of Health and Human Services, CMS

Description will be posted soon. Please check back.

Accountable Care Organizations & the Fraud Impact Mgmt Path
Wednesday, 2:15 p.m. - 3:15 p.m.
Level III

Jim McCall, AHFI
Director, Fraud Analytics, Emdeon

The presenter will provide a legal overview of Accountable Care Organizations (ACOs), to include a review of what they are, the objectives, how they operate, and how this type of care is changing or blurring the lines between payer and provider. In addition, the presenter will discuss some of the quality metrics, and how fraud risk associated with those submissions will need to be evaluated. Finally, the presenter will discuss the relationship between the shared savings methodology, and the NHCAA ROI Standards. He will explore more closely how the long held beliefs about prevented loss will need to be re-examined as provider performance will be measured by trending actual versus expected performance.

EHRs and the Fraud Potential Mgmt Path
Wednesday, 3:25 p.m. - 4:25 p.m.
Level II

Reed D. Gelzer, MD, MPH
HIT Policy and EHR Specialist, Provider Resources, Inc.

Electronic Health Records Systems (EHRs) are now used by the majority of practicing clinicians and hospitals. Currently, however, since there are no regulatory or "Certification" requirements that address their fitness for use as clinical or business records (or patient safety), EHRs are wildly variable in their ability to support or frustrate an investigator. Fortunately most organizations make a reasonable effort to use these systems properly but for those already disposed to fraud, they are a wealth of opportunities for taking advantage of any delays in payer attentiveness or adaptation. EHRs bring new tools and new challenges to the investigator, not the least being understanding and organizing greater volumes of complex data. This presentation will speed the adaptive investigator along the path to success in this new HCF landscape.

Fraud Under the Affordable Care Act: Year Two Mgmt Path
Thursday, 10:15 a.m. - 11:15 a.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 the opportunity for new fraud schemes within the exchanges, capitalizing on fraud units' experiences to date. Faculty will examine impact of the exchanges on the motivations and actions of individuals and small group employers and outline strategies to identify and prevent fraudulent claims. Faculty will also pose questions about the unknowns regarding tax credit and reimbursements and exchange enrollment policy and how each of these opens new doors to fraudulent activity.

Functional Medicine Mgmt Path
Thursday, 2:00 p.m. - 3:15 p.m.
Level III

Melissa Scott, CHC, CPC
President, ClinLab Consultants

Description will be posted soon. Please check back.

Government Anti-Fraud Initiatives: Perspective from the Outside Mgmt Path
Thursday, 2:00 p.m. - 3:15 p.m.
Level III

Peter P. Budetti, MD, JD
Attorney, Phillips & Cohen, LLP

Dr. Budetti, former Deputy Administrator with the Centers for Medicare and Medicaid Services, will share his experience and insight on the state of government anti-fraud initiatives. He will provide an insider's glimpse into the Healthcare Prevention Partnership administration and progress, discuss ACA regulations that have been released as well as those who have yet to be released, and share his perspective on Part C and D anti-fraud efforts, as well as ideas on what is needed to prepare for Accountable Health Organizations (ACOs).

Disability, Life, Long-Term Care & Workers' Compensation

 

Social Media and Investigations
Wednesday, 11:00 a.m. - 12:00 p.m.
Level II

Jason Caroluzzi
Vice President, Ethos Risk Services

Faculty will evaluate web-based information of value to an investigation. Topics discussed include the ethics and laws governing the use of social media in investigations, the indicators used in locating social information, and tips on using this information to enhance a claim investigation.

Member & Agent Fraud Schemes in Supplemental Insurance
Wednesday, 2:15 p.m. - 3:15 p.m.
Level II

Ronnie Rahe, AHFI
Manager, Supplemental Operations Review Team, HealthMarkets

Jennifer Sample, AHFI
Investigator, Supplemental Ops Review Team, HealthMarkets

The presenters will review and discuss in detail current member and agent fraud schemes experienced in supplemental insurance. This will include claim fraud and application fraud. In addition to explaining the fraud schemes and the impact to the supplemental insurance carrier, the presenters will also discuss how these schemes impact health insurance carriers. As an example, an individual who is attempting to prolong a disability or accident claim may continue to treat with a provider. While the supplemental carrier is paying the disability/accident, the health carrier is incurring costs of the unnecessary medical treatment.

Maximizing Witness Value during Patient and Provider Interviews
Wednesday, 3:25 p.m. - 4:25 p.m.
Level II

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

Mitchell Sherrod, AHFI
Medical Fraud Investigator, Travelers Insurance

Through examples and role playing faculty will demonstrate 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.

Disability Fraud AHFI Path
Thursday, 10:15 a.m. - 11:15 a.m.
Level II

Faculty TBA

The presenter will provide examples of current real world medical provider fraud schemes being perpetrated in the disability fraud arena, successful investigative techniques and requirements for prosecution. Disability fraud has long been a bastion for significant medical provider fraud, but has often fallen toward the bottom of priorities for law enforcement and prosecutors. The presenter will provide education on how investigators can detect the fraud; successfully procure the evidence necessary for successful prosecution; and the best methods for packaging the case for referral for prosecution based on real world examples.

Building a Model to Combat Workers' Compensation Fraud
Thursday, 11:30 a.m. - 12:30 p.m.
Level II

Ingrid Petrakis, RN, BSN
Claimant Fraud Specialist/Special Agent, United States Postal Service Office of Inspector General

Tracey Ruppel
Provider Fraud Specialist/Special Agent, United States Postal Service Office of Inspector General

Postal employees who suffer work-related injuries or illnesses receive compensation and medical benefits under the Federal Employee's Compensation Act (FECA), administered by the Department of Labor/Office of Workers' Compensation Programs (DOL/OWCP). In FY 2014, FECA benefits paid by the Postal Service totaled $1.32 billion. The Postal Service Office of Inspector General (OIG) has incorporated data mining and analytics in the area of workers' compensation fraud and built predictive models that assist in identifying claimants and medical providers who have a higher likelihood of being fraudulent. Built as a one stop shop for investigators, we will present the visualization of the models output which provides risk scores and immediate access to detailed claimant and provider data allowing investigators to be proactive and focus their attention on cases with the highest fraud probability. This session presents the use of both data analytics in support of claimant and provider fraud investigations from the perspective of Criminal Investigators. An overview of the applications and models used is given, along with case studies that showcase the return on investment that can be expected.

Workers' Compensation: a Grant Funding Model to Bolster Anti-fraud Efforts
Thursday, 3:30 p.m. - 5:00 p.m.
Level II

Dominic Dugo
Chief, Insurance Fraud Division, San Diego County District Attorney's Office

Alan Kessler, JD
Deputy District Attorney, Workers' Comp Applicant Team Leader, San Diego County District Attorney's Office

As a result of the serious problem of WC fraud, California has established grant funding of approximately $55 million a year for anti-fraud efforts. We will explain how the grant funding process operates and the success California has had investigating and prosecuting workers' compensation fraud. Faculty will demonstrate through a case study best practices in a claimant fraud case.

Anti-Fraud Technology Solutions

 

SIU Best Practices Panel
Presented by GDIT, an NHCAA Platinum Supporting Member
Wednesday, 9:15 a.m. - 10:15 a.m.
Level II

Jala Attia, AHFI
Senior Program Director of Business Process Outsourcing and Special Investigations Unit Services (SIU), General Dynamics Health Solutions

Linda Gilbreath, CPC, CPC-I, CPC-H, CEMC, AHFI, CHCA
Senior Manager of the Medical Review Team, General Dynamics Health Solutions' Anti-Fraud Services

Mark Starinsky, AHFI, CFE
Manager of Investigations, General Dynamics Health Solutions' Anti-Fraud Services

Participants will benefit from learning best practices that have demonstrably improved the effectiveness of an SIU and the quality of its investigations. This session will provide insights and examples of areas that are often overlooked, but when given attention, can help establish and maintain a strong foundation for your FWA Program. Faculty will also explore how attendees can get the most out of their FWA vendors.

Addressing Evolving Threats in Fraud, Waste and Abuse
Presented by Truven Health Analytics, an NHCAA Platinum Supporting Member
Wednesday, 9:15 a.m. - 10:15 a.m.
Level II

David Nelson
VP, Truven Health

Mark Gillespie
VP, Truven Health

David Hart
Senior Director, Truven Health

Fraud schemes are continuing to evolve at a staggering rate and the growing Medicaid managed care environment is presenting unique risks for fraud, waste, and abuse. That's why it's important for payers to have proven detection and control processes in place - processes that can address and anticipate the program abuse, wasteful spending, and fraud schemes. Join Truven Health experts as they discuss new innovations in fighting fraud waste and abuse in a managed care environment, including predictive modeling, and key algorithms from the industry's largest algorithm database. During this session, presenters will review fraud solutions, schemes, key algorithms, predictive analytics, technical and analytic approaches, and trends seen in the U.S. with a focus on what works to prevent fraud, waste, and abuse in the health care payer world. Truven Health has been helping Medicaid agencies, CMS, analysts and SIU departments in identifying, recovering and preventing fraud, waste and abuse for more than 30 years.

How A Multi-pronged Approach and Use of Visualization is Most Effective to Reduce False Positives and Maximize FWA Initiatives
Presented by Emdeon, an NHCAA Platinum Supporting Member
Wednesday, 11:00 a.m. - 12:00 p.m.
Level II

Louise T. Dobbe, Esq.
Director, Investigative Operations and Analytics, Emdeon

Brad Vinson, CPC-P
Senior Investigator, Investigative Operations and Analytics, Emdeon

Learn how a multi-pronged approach is more effective in identifying potential FWA cases. This includes analytics with multi-plan data sets, complex code edits, investigative flags, and human review to uncover high risk claims. Using any single technique is less effective than combining a string of techniques in reducing false positives and maximizing initiatives. Effective identification techniques are the first component. The second is presenting visualizations that illustrate the significance of your findings. Discover how visualizations can impact your findings and the message you deliver. Examples highlight cases where these techniques were used to effectively identify and resolve high risk cases.

Six Degrees of Separation: Fueling investigations with insight into hidden and complex relationships, associations, and affiliations
Presented by LexisNexis, an NHCAA Platinum Supporting Member
Wednesday, 11:00 a.m. - 12:00 p.m.
Level II

Mark Isbitts
Director, Market Planning - Payment Protection, LexisNexis

Health care costs continue to rise, affecting everyone involved -- patients, providers, insurance companies and other organizations. While many efforts have been made to control those costs, including the federal government's health care reform law, the Patient Protection and Affordable Care Act, many observers say efforts haven't gone far enough in solving one of the top problems in medicine today: health care fraud, waste, and abuse (FWA). The future of FWA detection involves the overlaying of linking analytics to internal and external data sources. This approach helps uncover significant links among individuals, businesses, assets and properties. Coupling this powerful capability with claims, public records, and contributory data unlocks hidden patterns that otherwise could adversely impact an organization's bottom line, regulatory compliance goals and patient safety. This session will address the importance of looking at providers as people, understanding relationships among providers, patients, and business' and how linking analytics provides visibility into hidden fraud across provider networks.

Collaboration in Fighting Fraud
Presented by Verisk Health, an NHCAA Platinum Supporting Member
Wednesday, 2:15 p.m. - 3:15 p.m.
Level II

Daniel Kreitman
Director, Special Investigations Unit, Centene Corporation

Jim Schweitzer
Senior Vice President and Chief Operating Officer, NICB

Doug Coombs
Vice President, Fraud Solutions, Verisk Health

Understanding Pharmacy Operations - A Key for Investigators
Presented by Xerox, an NHCAA Platinum Supporting Member
Wednesday, 3:25 p.m. - 4:25 p.m.
Level II

Joshua Peters, PharmD, RPh
Pharmacy Claims Auditor, FWA Specialist, Xerox

Casey H. Chandler
FWA Product Manager, Xerox

Understanding the daily operations of a typical pharmacy, and the regulations governing pharmacy practice can give investigators deeper insight to identify improper activities. Join experts from Xerox for an inside view of pharmacy operations. You will learn how pharmacies must align with rules and regulations, and conform to best practices. Our experts will highlight how wasteful, abusive, and atypical dispensing can affect quality of care, and cause financial harm. We will demonstrate proper record-keeping, and tie it to traditional audit and investigative functions. With this expanded understanding, investigators may find irregular activity that completes the picture of a suspect pharmacy.

Expanding Beyond Facility RAC Audits with Adaptive Predictive Analytics
Presented by FICO, an NHCAA Platinum Supporting Member
Wednesday, 3:25 p.m. - 4:25 p.m.
Level II

Allyn Pon
Senior Product Manager, FICO

Todd Higginson
Senior Director, Product Marketing, FICO

Determining the optimal program integrity strategy for facility claims is an ongoing challenge for most healthcare payer organizations. The complexity of inpatient and outpatient facility claims coupled with complicated medical policy compliance makes the review process demanding, labor-intensive, arduous, and slow. Many payers and government entities depend on recovery audit contractors (RAC) to perform a majority of their fraud investigations for facilities. Many of the RAC issues are covered by well-defined local coverage determination (LCD) or national coverage determination (NCD), which identify specific combinations, procedures, drugs, and/or diagnoses. While this is proven to be effective, there's still more money on the table being lost because of new systemic problems that go undiscovered. And while thousands of rules/concepts by Recovery Audit Contractors (RACs) can ferret out specific fraud, waste and abuse issues, only adaptive predictive analytics can identify hidden egregious errors, and discover new and emerging problems. Learn how a comprehensive program integrity strategy can help address complex facility claims.

Will Fraud, Waste, Abuse Exist in an ACO World?
Presented by CGI Federal Inc., an NHCAA Platinum Supporting Member
Thursday, 8:15 a.m. - 9:30 a.m.
Level II

Robert Haskey, MD
Senior Medical Director, CGI Federal, Inc.

Join this presentation that will explore the world of Accountable Care Organizations, the concepts that have led to same, and the architecture of this 21st century effort to link beneficiary, provider, and payer in a new way to achieve improved health care outcomes in a more cost effective manner. Understand the nature of what constitutes the ACO reimbursement model from both a CMS as well as Commercial Payer perspective. Is the ACO a reimbursement variation of an old theme? Will it replace traditional fee-for-service models? Is there a place for audit in this new world? What tools and approaches will you need to secure your Plan's financial future? Through a better understanding of an ACO world, you can be prepared.

Future Fraud Busters: How Integrating Clinical and Claims Platforms, and Applying New Predictive Models to Behavioral Health Will Change the Industry
Presented by HMS, Inc., an NHCAA Platinum Supporting Member
Thursday, 10:15 a.m. - 11:15 a.m.
Level II

Spencer Young
Senior Vice President of Clinical Operations, HMS

Geetu Melwani, Ph.D.,
Senior Director of Clinical Analytics, HMS Permedion

As healthcare dollars grow tighter, payers must make major technological advancements to contain fraud - a $70 billion a year problem. This presentation addresses two of the latest ways to respond: 1) Shift cost-containment efforts from recovery to prepay. By recently combining a prepay audit platform with a postpay clinical platform, HMS shares best practices that payers can use to stop erroneous payments before they happen. 2) Apply new predictive models to behavioral health claims. The application of fresh variables based on linear regression to existing systems promise to increase recovery rates by up to 30%. Investigators will learn about the key variables to help reduce false positives - and target the most significant fraudulent claims. The presentation includes mini-case studies from both commercial and government payers, illustrating the diverse ways to use technology to fight healthcare fraud in the 21st century.

New Payment Frontier and the Data Challenges it Presents
Presented by SAS, an NHCAA Platinum Supporting Member
Thursday, 10:15 a.m. - 11:15 a.m.
Level II

Rick Sluder, CFE
Senior Solutions Architect, SAS

Ross Kaplan
Principal Solutions Architect, SAS

To prepare for the data challenges of 2015 and beyond, government funded and commercial insurance plans need a data management infrastructure that provides access to data across programs, products and channels. It doesn't require a database overhaul, but rather a data integration layer that can source from databases around the organization, business partner organizations, social media outlets, and from external public or purchased data. Because unscrupulous providers and suppliers often intentionally provide inaccurate, incomplete or inconsistent information to prevent records matching across disparate systems, government funded and commercial plans need data quality capabilities that support entity resolution. Since the devil is in the details, the data management, integration, and quality infrastructure must be supported by a robust business analytics foundation. To make proper use of internal and external data sources, the business analytics foundation must provide a variety of analytic processes to identify suspicious patterns that could point to programmatic fraud, waste, or abuse. Time is money, and in this new payment frontier, government-funded and commercial plans need an infrastructure designed to stop the improper payments, instead of chasing them down after the money is long gone.

 

Breakfast Sessions - start the day with eggs and education!
Thursday, 7:00 a.m. - 8:00 a.m.

 

Predictive Analytics is more than just an industry buzzword and the distinction matters to SIUs
Presented by BAE Systems, an NHCAA Premier Supporting Member
Level II

Richard Graham
Senior Solutions Consultant, BAE Systems Applied Intelligence

Garrett Biemer
Technical Lead, BAE Systems Applied Intelligence

Even as more and more controls are put in place to stop fraud, waste, and abuse, the problem gets larger every year. This coupled with limited resources, means special investigations units need to be incredibly efficient. A key to making this happen is leveraging the latest and greatest technology to manage instances of FWA. This presentation will focus on how payers can build special investigations units using cutting edge predictive analytics technology.

Combining Medical and Pharmacy Data to Drive Compliance and Detect Fraud, Waste and Abuse 
Presented by Health Care Excel, Inc, an NHCAA Premier Supporting Member

Paul Dausman
Chief Information Officer, Health Care Excel, Inc.

Medical and pharmacy data are often reviewed in their own silos when it comes to examining the care and behavior of a patient or provider. Medical diagnoses and procedures should lead to appropriate prescribing patterns. Conversely, the presence of pharmacy script activity should tie back to an appropriate medical diagnosis. Gaps in these patterns of script or diagnosis activities are a strong indicator of wasteful non-adherence, fraudulent provider behavior or abusive use. This session will discuss methods and metrics for capitalizing on what combined medical and pharmacy data can reveal to us.

Effectively Integrating External Data into your Investigation
Presented by Healthcare Fraud Shield, an NHCAA Premier Supporting Member

Tony Rademeyer, MBA
EVP, Sales, Healthcare Fraud Shield

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

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

Attendees will learn how to identify data resources and key industry websites to obtain information that will enhance their investigations. Many of these resources are available to the public and laden with valuable information that can be incorporated into investigators day to day proactive and reactive analysis. For example, the CMS website contains a myriad of rich data sources such as a list of surgical procedures and the estimated time it takes to perform each of those procedures. This dataset can be downloaded and incorporated into an SIU's FWA efforts. In addition to the data sources found on the CMS website, there are numerous other data sources that can be fused with provider and claims data to identify potential FWA.

Stop Fraudsters in Their Tracks and Prevent Profit Leakage
Presented by IBM, an NHCAA Premier Supporting Member

It is estimated that $3.5 trillion is lost each year to fraud and financial crimes. More and more, public and private enterprises are using sophisticated analytics coupled with business expertise to address this enormous challenge. Gartner has estimated that 25% of all large companies will in fact adopt such solutions for security or fraud detection by 2016, resulting in ROI within 6 months of adoption. We are working with private and public clients across many industries to help them adopt a multilayered approach to stop all types of fraud, from organized fraud to opportunistic fraud and from financial crimes and regulatory abuses (both legal and illegal) to waste and error as the result of poor policies or poor execution. Clients are struggling with availability of IT, data analyst, and investigative resource coverage to assist -- IBM is here to help! Our counter fraud framework solves a wide array of fraud business problems by using advanced analytics and statistics, is delivered through flexible engagement models (including cloud, gain share, and as-a-service models), and is backed by continuous innovation from IBM Research and IBM Watson.

Pharmacy Claims Advanced Data Analytics
Presented by SCIO, an NHCAA Premier Supporting Member

Rena Bielinski, Pharm.D., AHFI
SVP, Chief Pharmacy Officer, SCIO Health Analytics

Mark Lavallee
Sr. Vice-President, Sales, SCIO Health Analytics

Specialty drug spending saw a record increase in spending in 2014. Advanced analytics can reduce costs for PBMs and Health Plans alike. Topics of discussion will include: member drug seeking behavior identification - can be due to addiction or drug diversion and collusion - for every $1 of abused drugs, and additional $50 is wasted on related medical claims; J code to NDC comparison to identify potential overlap in payment under both the pharmacy and medical benefit; compound analysis representing a disproportionate amount of fraudulent claims, trends and billing spikes can be identified early, pharmacy report cards and fraud dashboards.