Conference Sessions

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Level I
Basic programs where 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.

LEL Path This path leads law enforcement and investigators working in public programs to sessions most applicable to their needs.

For a printable version, please download the Full Conference Agenda

NEW AND TRENDING FRAUD SCHEMES

 

ACA Basics for Fraud Investigations and Identifying Trends and Schemes
WEDNESDAY, NOVEMBER 16  | 9:45 am - 10:45 am
Level I

The Affordable Care Act (ACA) expands the affordability, quality, and availability of private and public health insurance through consumer protections, regulations, subsidies, taxes, insurance exchanges, and other reforms. In 2014, the ACA enacted the minimum essential coverage requirement for all persons which introduced a new type of healthcare coverage option for millions of people. Unfortunately, the new healthcare coverage option has also led to new types of fraud schemes perpetrated by doctors, patients and brokers. In this session, the faculty will provide a general overview of ACA basics discussing the difference between on and off Marketplace plans as well as a case study to provide the attendees with actionable steps to mitigate risk with your own plan. Topics will also include open enrollment vs. special enrollment red flags as well as how to proactively monitor enrollment.

Aneta Andros, AHFI
Fraud Manager, Cigna

Tom Hixson
Audit Director, Cigna

Marketplace Fraud: A Deep Dive into this New Fraud Scheme
WEDNESDAY, NOVEMBER 16 | 11:00 am – 12:00 pm
Level II

Marketplace Fraud or fraud on the health insurance Exchanges has increased as the ACA has moved into its fourth year of implementation. In this discussion, representatives from multiple health insurers will discuss the types of fraud being seen on some of the largest Exchanges. The panelists will discuss trends in fraud schemes and red flags, and offer insight into what steps should be put into place at your organization.

Dan Edwards, CFE
Director, Special Investigations Unit, Anthem, Inc. (moderator)

Darrell S. Langlois, CPA, CIA, AHFI
Vice President, Compliance, Privacy & Fraud, Blue Cross Blue Shield of Louisiana

Jonnie Massey, CPC, CPC-P, CPC-I, CPMA, AHFI
Director, SIU, Blue Shield of California

Larry Turso
Senior Investigator, Anthem, Inc.

Genetic Testing Schemes: Trends, Investigative Steps and Shared Experiences
WEDNESDAY, NOVEMBER 16 | 2:15 pm - 3:15 pm
Level II

Health insurers are being inundated with claims for all different types of genetic laboratory testing. The claims being submitted, as well as the utilized testing methodology, are confusing and difficult to audit. This presentation will provide SIU investigators with the tools and techniques necessary to conduct an investigation including member and provider interviews, online message board review, and data mining. The presentation will also discuss some of the common provider defenses and suggest ways to successfully counter those defenses.

Jessica Roy, CFE
Investigator, Harvard Pilgrim Health Care, Inc.

Priscilla J. Alfaro, MD, FAAP, CPC, CPMA, COC, CFE
National Medical Director for Reimbursement Policy Management, Anthem, Inc.

Anne Louise Smith, AHFI, CFE
Senior Investigator, Anthem, Inc.

Chasing the Dragon: Addressing the Country’s Opioid Addiction – Part I & IILEL Path
WEDNESDAY, NOVEMBER 16 | 3:25 pm - 5:15 pm
Level I

An opioid and prescription drug abuse epidemic is sweeping the country, impacting all segments of society. To help raise awareness of this epidemic and to help educate young people on the dangers of addiction, the FBI and DEA have released the documentary Chasing the Dragon: The Life of an Opiate Addict, a compilation of heart-wrenching first-person accounts by addicts and family members of addicts about their experiences. This two-part session will host a special viewing of the documentary will be shown followed by a discussion with agents involved in the cases, the challenges with opioid addiction, and tips for law enforcement and insurers in fighting this epidemic.

Shane Dana
Special Agent, Washington Field Office, U.S. Department of Justice, Federal Bureau of Investigation

Charles Baker Doughty
Special Agent, Washington Field Office, U.S. Department of Justice, Federal Bureau of Investigation

Emerging Issues in MedicareLEL Path
THURSDAY, NOVEMBER 17 | 10:30 am – 11:30 am
Level II

Participate in this annual 'Health Care Fraud Trends' presentation with one of the leading experts from HHS-OIG on common fraud schemes, emerging trends, data analysis, special initiatives, and specialty areas affecting Medicare and Medicaid. Attendees will enjoy an entertaining and insightful session that is always a hit.

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

Developing your FWA Strategy for Sober Homes
THURSDAY, NOVEMBER 17 | 1:00 pm – 2:00 pm
Level I

This panel of healthcare experts will discuss the current landscape of sober living homes and residential treatment facilities and the potential fraudulent/abusive over testing and billing that is associated with them. The speakers will also explore some of the legal, medical, and other investigative challenges associated with sober homes. The panel will offer insights into some of their investigative techniques and strategies used to address this new epidemic.

Jesus Barranco
Special Agent, U.S. Department of Health and Human Services OIG

Christa Jewsbury, JD, CFE, AHFI
Director, Special Investigations Unit, Humana

Tim Dineen, CFE, MPA
Director, Special Investigations, Horizon Blue Cross Blue Shield of New Jersey

William Stewart
Special Agent, U.S. Department of Justice, Federal Bureau of Investigation

David Popik, CFE, AHFI
Senior Director, SIU/Physician Ancillary, Florida Blue

Medical Identity Theft and Cyber Attacks: Responding to the New World
THURSDAY, NOVEMBER 17 | 2:15 pm – 3:15 pm
Level II

Healthcare data is a treasure trove of information and criminals are launching ever-more aggressive, targeted attacks to get it. In today’s world of cyber attacks and data breaches, sensitive information is readily exposed and consumers are increasingly vulnerable to medical identity theft and healthcare fraud. While last year quickly became the year of the healthcare breach, this year saw a surge in ransomware and spear phishing attacks, to name a few. According to the latest Ponemon Institute report on medical identity theft, the number of victims has nearly doubled in five years. Will this number continue to grow exponentially? Many healthcare providers are taking proactive measures and exploring new ways to protect patient privacy. Is it enough? Are healthcare organizations working with law enforcement early on? All government fronts are stepping up fraud protection and cracking down on healthcare fraud. Are the efforts helping? Or, as an industry, are we plugging holes only to find new holes. This panel will take a look at 2016 to review medical identity theft and healthcare fraud from three perspectives: consumer, health plan, and legal/regulatory to explore what’s at stake, discuss the issues and pain points, outline the trends, and examine solutions.

Christine Arevalo
Vice President, Healthcare Fraud Solutions, ID Experts (moderator)

Toni Slocum, AHFI, CPC, CPCP
Supervisor, Special Investigations Unit, Moda Health

Ann Patterson,
SVP & Program Director, Medical Identity Fraud Alliance

Sean Hoar
Partner, Davis Wright Tremaine 

Prosecuting a Health Care Fraud Scheme Resulting in DeathLEL Path
THURSDAY, NOVEMBER 17 | 3:30 pm – 4:30 pm
Level II

The presenters will discuss the “but for” cause standard for health care fraud (Title 18 USC 1347) violations resulting in death and/or serious bodily injury. The presenters will address the challenges, advantages and lessons learned from trying a health care fraud death case. During the presentation, participants will learn about the commonly misused radiology CPT and transportation HCPCS codes in portable X-ray fraud cases. Participants will learn simple methods to identify potential fraud associated with portable X-ray suppliers when examining health insurance claims data. Additionally, in cases potentially involving patient harm/death, the presenters will explain how health insurance claims data was used to identify victims in the case. Lastly, the presenters will discuss the investigative techniques utilized by the team, including the coordination of medical experts, which resulted in a successful health care fraud “death” prosecution.

Leo J. Wise
Assistant United States Attorney, U.S. Attorney's Office for the District of Maryland

P. Michael Cunningham
Assistant United States Attorney, U.S. Attorney's Office for the District of Maryland

The Challenges of an International Health Care Market
FRIDAY, NOVEMBER 18 | 9:30 am - 11:30 am
Level II

Part I – Trends, Schemes and Vulnerabilities

This two-part workshop will address the trends and schemes of international health care fraud. In part I, our faculty, Dr. Simon Peck offers his insights from his experience with a multinational provider of health insurance on health care fraud schemes and trends throughout the globe. Dr. Peck will discuss the particular vulnerabilities for organizations in the international markets and offer specific case examples from Europe, Asia and Arabian Gulf regions. He’ll also offer technical expertise on how companies can assess their risk and implement a successful anti-fraud strategy.

Simon Peck, MD
Head of Investigations and Medical Advice, Provider Management, AXA PPP Healthcare

Part II - Foreign Claims Fraud

In part two of this workshop, attendees will take a closer look at foreign claims from with two leading U.S. based health insurance plans. Foreign claims fraud is a risk to members/patients as well as risk to health plans that are paying claims for services that may be, investigational and experimental, dangerous, inflated or simply not rendered. Health Plans may not realize the exposure to foreign claims fraud without the tools to identify the behavior, prevent and recover overpayments and prosecute the criminal acts. Two health insurance leaders will offer attendees training from their extensive experience investigating foreign claims fraud and developing effective programs to identify and reduce payments related to this particular type of fraud. Attendees will gain valuable insight including reviewing examples and learning about schemes and trends in foreign claims fraud.

Jonnie Massey, CPC, CPC-P, CPC-I, CPMA, AHFI
Director, SIU, Blue Shield of California

David Popik, CFE, AHFI
Senior Director, SIU/Physician Ancillary, Florida Blue

EXPANDING YOUR INVESTIGATIVE SKILLS

 

Techniques for Using Technology in Fraud InvestigationsLEL Path
WEDNESDAY, NOVEMBER 16 | 9:45 am - 10:45 am
Level II

The main topic of the presentation is how technology has changed healthcare fraud investigations, both in detection and prevention. Topics will include health information technology, electronic search warrants, electronic medical records, fraud detection methods and tools, using social media to collect evidence, and the use of covert electronic devices to collect evidence in healthcare fraud investigations. Lastly the presenters will provide case studies where covert electronic techniques and methods we used successfully.

Daniel Arce
Special Agent, U.S. Department of Health & Human Services OIG

Radu Pisano
Special Agent, U.S. Department of Health & Human Services IOG

Leveraging Public Resources in an Investigation
WEDNESDAY, NOVEMBER 16 | 11:00 am – 12:00 pm
Level I

This session will provide a comprehensive training to show users various public resources and methodologies that can be leveraged within an investigation via the Internet. During the session several basic elements will be reviewed, such as searching the List of Excluded Individuals and Entities (LEIE) and Divisions of Corporations; however, more complex Internet resources will be discussed, e.g. IP Address Decoders, EXIF Readers to view Metadata, Reverse Email Address Logic, Search Engines – Beyond the Norm, Archive Web Portals, etc. The Internet is an important tool that should be leveraged during every investigation. After the closing of this session attendees will have new tools to use when “digging” into an investigation and uncover the “dirt” scattered throughout the web.

Matthew Berls, MA, AHFI
Director, SIU, UnitedHealthcare Investigations

Kelly Tobin, AHFI, CFE
Director, SIU, UnitedHealthcare Investigations

Interviewing Skills and Interpreting Body Language and Voice Cues
WEDNESDAY, NOVEMBER 16 | 2:15 pm - 3:15 pm
Level I

This session is designed to provide an investigator with insight into how to conduct proper interviews of investigative subjects and evaluate the body language and voice queues given by the subject to better know what the subject is not only verbally saying, but behaviorally communicating. The speaker will provide an overview of proper interview/question organization and the importance of objectives being established for onsite visits and interviews. Numerous physiological indicators of deception, stress, truthfulness, etc. will also be addressed and provided to the audience.

Don R. Wakefield, JD, DC, PA
President & CEO
International Healthcare Consultants, Inc.

Persaud Interventional Cardiology Case StudyLEL Path
WEDNESDAY, NOVEMBER 16 | 3:25 PM – 4:25 PM
Level I

The presenters in this session will discuss the investigation and trial of Dr. Harold Persaud, an Ohio-based interventional cardiologist who was convicted on health care fraud, false statements related to health care matters, and one count of engaging in monetary transactions in property derived from criminal activity. Attendees in this session will hear how a comprehensive review of Persuad’s entire practice, data analysis, expert testimony, and records played a role in the investigation, trail and conviction of Dr. Persaud. Attendees will be shown the necessity of comparing provider documentation to claims data, patient interviews, and other billings, such as hospital records, to obtain a comprehensive understanding of the fraud scheme. Attendees will also be shown how diagnostic testing and procedures can be used to justify invasive procedures, creating a cycle of fraudulent billing and patient harm.

John Leahy
Special Agent, U.S. Department of Health & Human Services IOG

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

Matthew Beckwith
Forensic Accountant, U.S. Department of Justice, Federal Bureau of Investigation

Preparing for Provider Audits
WEDNEDAY, NOVEMBER 16 | 4:30 – 5:15 pm
Level I

Auditing a provider practice is typical for most fraud investigations. In this session, our speaker will provide a framework for how to prepare for the onsite audit, what to plan for, and what to expect. Take away best practices for your own investigations and learn new techniques that will help your next investigation.

Jonnie Massey, CPC, CPC-P, CPC-I, CPMA, AHFI
Director, SIU, Blue Shield of California

Interoperability: Identifying, Reducing IT Vulnerabilities in Safety, Security, Fraud and Cyber Crime
THURSDAY, NOVEMBER 17 | 10:30 am – 11:30 am
Level II

This presentation will outline the need to expand proactive, preventive approaches to vulnerabilities likely to expand in parallel with health care interoperability improvements. The speakers will shed light on the potential fraud and patient harm from exploitable interconnected cyber systems, electronic semantics platforms, such as medical identity theft and records counterfeiting. The speakers will also examine the emerging fraud, waste and abuse in Electronic Health Records will be fully addressed as well as the future for syntactic interoperability.

Alanna Lavelle, MS, AHFI, CPC
Special Advisor, The MITRE Corporation

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

Best Practices in Case Documentation
THURSDAY, NOVEMBER 17 | 1:00 pm – 2:00 pm
Level I

Case documentation and thorough notations can draw you away from the important work but maintaining detailed records can have a significant impact on the success of an investigation and prosecuting a case. Learn the importance of documenting an investigation in a comprehensive and detailed manner. The audience will learn methods in presenting evidence in an objective, organized and factual fashion. Participate in this session to better understand best practices and procedures that minimize risk.

Matthew Berls, MA, AHFI
Director, SIU, UnitedHealthcare Investigations

Tamara Neiman
Director, National Special Investigations Unit, Kaiser Permanente

Pre-pay FWA Detection System: An Ounce of Prevention is Worth a Pound of Cure
THURSDAY, NOVEMBER 17 | 2:15 pm – 3:15 pm
Level II

Under new authorities granted by the Affordable Care Act, the industry continues to move away from “pay and chase” towards preventing health care fraud and abuse in the first place. The presenters will show how Aetna follows this initiative closely and develops a comprehensive, preventive and intelligent analytical framework for detecting fraudulent, abusive and wasteful claims in near real time through advanced machine learning techniques. The speakers will provide a quick overview of the Aetna in-house pre-pay FWA detection framework and demonstrate how it is used to discover specific FWA scenarios identified in the most recent months.

Aleksandar Lazarevic
Senior Director, Data Science Organization, Aetna

Marinka Natale
Senior Director, Data Science Organization, Aetna

Richard Statchen
Manager of Informatics, Special Investigation Unit, Aetna

Developing a Hands-on Approach to Medical Record Review
THURSDAY, NOVEMBER 17 | 3:30 pm – 4:30 pm
Level I

Healthcare fraud investigations often boil down to the question, “Does the medical record support the billed service(s)”. Investigators who do not possess a fundamental understanding of medical records’ anatomy are unable to answer that question or be adequately equipped to discuss such imperative aspects with a clinician preparing to conduct a medical necessity and appropriateness review. Medical record examples will include a variety of provider specialties including, but not limited to, acupuncture, behavioral health, chiropractic, evaluation & management, home health care, laboratories, physical therapy, and specialty pharmacy. Furthermore, this presentation will review potential action payers can take based upon non-clinical review findings, which may occur several months before action is available post-clinical review. This presentation will encourage and enable healthcare fraud investigators to take the must-needed hands-on approach towards medical record reviews while debunking the mindset that they cannot do so for the sole reason that they are not clinicians.

Greta Matus, CPC, CMBI
Senior Fraud Investigator, Cigna

Sean Petree, AHFI
Case Development Team Lead, Special Investigations Unit, Cigna

Statistics - Friend or Foe? The Data Analyst’s Perspective
FRIDAY, NOVEMBER 18 | 9:30 am – 11:30 am
Level I

Statistics, data analytics, data mining, and overpayment extrapolation using statistical concepts, including sampling, have become more prominent tools in the healthcare enforcement community’s war chest. Many statistical terms and concepts may appear too complicated or even intimidating. There are, however, some basic concepts and when applied can render a powerful tool in evaluations, auditing, monitoring, detecting that is worth getting more familiar with. Attendees will be introduced to basic statistical concepts and more importantly how to implement them in their analysis or investigation; and in addition, how to understand the results generated from this techniques. During the session, the presenters will illustrate the various techniques and provide real examples.

Paulo Macedo, PhD
Senior Statistician, Integrity Management Services, Inc.

Sewit Araia, MPH
Data Manager and Statistician, Integrity Management Services, Inc.

CLINICAL ISSUES FOR THE HEALTH CARE FRAUD INVESTIGATOR

 

Medical Director’s Perspective on FWA Strategy for 2017 and 2016
WEDNESDAY, NOVEMBER 16 | 9:45 am - 10:45 am
Level II

Medical Directors from across the health insurance industry will offer insight and perspective on the leading issues in health care fraud from their position in the organization. The panel will examine the challenging clinical issues trending and the evolution of new issues. Participate in the session and have the opportunity hear from leaders from the public and private sectors to gain insights on the challenges and accomplishment over the past year along with the on-going challenges moving forward.

Kristine Bordenave, MD, FACP
Lead Medical Director, Special Investigations Unit & Provider Payment and Integrity, Health Guidance Organization, Humana (moderator)

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

Elaine K. Jeter, MD
MolDx Medical Director, Palmetto GBA

Simon Peck, MD
Head of Investigations and Medical Advice, Provider Management, AXA PPP Healthcare

Shantanu Agrawal, MD, MPhil
Deputy Administrator & Director CPI, U.S. Dept. of Health & Human Services, CMS

Mental Health and Substance Abuse Privacy: Challenges and Opportunities
WEDNESDAY, NOVEMBER 16 | 11:00 am – 12:00 pm
Level I

HIPAA privacy regulations and substance abuse law restrict access to psychotherapy notes and substance abuse records; however, this does not mean that the entire chart is restricted. This session will discuss the challenges and opportunities that are presented under these regulations. The speakers will explain the various components of a psychotherapy chart and provide strategies beyond the medical record request to obtain information when auditing or investigating a behavioral health provider. Case examples will be shared to demonstrate strategies for reviewing psychotherapy charts.

Jodi L. Smith
Investigator, Aetna

Christy Thawley, MSW, LCSW-C
Fraud Specialist, Corporate Audit - Special Investigations Unit, Cigna

Ophthalmological Fraud: Understanding Common Retinal Diseases and Fraud
WEDNESDAY, NOVEMBER 16 | 2:15 pm – 3:15 pm
Law Enforcement Track
Level II

Ophthalmology expenditures by Medicare are one of the fastest-growing specialty areas, nearly doubling in the last decade. With our ever-aging population, cataracts, glaucoma and wet macular degeneration are diagnoses that are certain to be seen with increasing frequency in the future. Because of the visual nature of the tests commonly used in retinal ophthalmology, providers who misdiagnose ophthalmological conditions (wet macular degeneration, glaucoma, diabetic retinopathy, etc.) often leave a distinct and incontestable record via the diagnostic tests. Additionally, the effects of laser treatments also leave a visible record on any subsequent tests. Attendees will learn ophthalmological data comparison techniques, trends suggestive of problematic providers, inconsistencies and discrepancies in ICD-9 and CPT codes to help identify fraud, and be able to identify the differences between clean diagnostic tests and those indicative of common retinal diseases.

Christian Jurs
Special Agent, U.S. Department of Health and Human Services, Office of Inspector General

Bariatric Surgery Fraud: Scrutinizing Billing Patterns and CPT Codes
WEDNESDAY, NOVEMBER 16 | 3:25 pm – 4:25 pm
Level II

There is an increasing trend for members to obtain bariatric surgery to combat morbid obesity. Due to several limitations such as no bariatric coverage under their plan, high out of pocket costs, not meeting criteria for bariatric surgery, providers have come up with different schemes to get insurers to pay for other surgeries to defray out of pocket costs for members. The speakers will address masking bariatric surgery, hernia repair procedures, appropriate and inappropriate CPT codes, and medical record documentation.

Kathy Richer, RN, BSN, AHFI
Supervisor, SIU, Aetna

Susan Lee, RN, CHCQM, CCS-P, AHFI
Senior Investigator, SIU, Aetna

Medicare Part D Fraud: Investigating and Prosecuting Complex SchemesLEL Path
WEDNEDAY, NOVEMBER 16 | 4:30 pm – 5:15 pm
Level I

Over the past few years, the OIG has investigated and prosecuted a complex pharmaceutical scheme in southern Florida that involved kickbacks, false claims, patient recruiters, and Medicare beneficiaries for fake prescriptions. Hear about how investigators and agents were able to successfully track the activities of this multi-layered case through inter-agency efforts. Attendees will gain a better understanding of how to collaborate across agencies, and strategies for investigating complex fraud schemes.

Stephen Mahmood
Special Agent, U.S. Department of Health & Human Services, Office of Inspector General

Medical Necessity: Creating a Consistent, Reproducible Approach to Audits
THURSDAY, NOVEMBER 17 | 10:30 am – 11:30 am
Level II

With medical necessity as the over arching criteria for E/M services, providers and auditors can stop obsessing over the number of bullets and focus on what was done for the patient. This session will assist auditors to focus on the more objective components of the E/M and develop a process that is consistent and reproducible across an entire team.

Karna Morrow, CPC, RCC, CCS-P
Manager, Consulting Services, Coding Strategies, Inc.

Emerging Threats: PharmaceuticalsLEL Path
THURSDAY, NOVEMBER 17 | 1:00 pm – 2:00 pm
Level II

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

Michael Cohen, DHSc, JD, PA-C
Inspector, U.S. Department of Health & Human Services, Office of the Inspector General 

Shimon R. Richmond
Special Agent in Charge, Miami Regional Office, Office of Investigations, OIG, U.S. Dept. of Health & Human Services

Florida Phantom Provider InitiativeLEL Path
THURSDAY, NOVEMBER 17 | 2:15 pm – 3:15 pm
Level II

The phantom provider issue has been a problem particularly in South Florida for many years. However, more recently the efforts of the healthcare SIUs, with the assistance of local, state and federal law enforcement has taken a huge dent out of their fraudulent behavior. Learn about the outstanding partnership between two separate Blue Cross Blue Shield plans which has resulted in the identification of millions of dollars of fraudulently billed dollars to the healthcare industry with phantom providers discovered, shut down, and referred to law enforcement.

Tim Thacker
Manager, Special Investigations Unit, Florida Blue

Kimberly Obermeyer, AHFI, CFE
Senior Investigator, Anthem, Inc.

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

Defrauding Worker’s Compensation: Operation Back LashLEL Path
THURSDAY, NOVEMBER 17 | 3:30 pm – 4:30 pm
Level II

Operation Back Lash was a ground breaking 4-year multi-agency undercover operation initiated to combat entrenched corruption in the California Worker’s Compensation System (CWCS) private insurance program. The loss to the CWCS was estimated to be in excess of half a billion dollars. Liaison between law enforcement, the International Association of Special Investigation Units (IASIU), and the National Insurance Crime Bureau (NICB) in San Diego revealed rampant criminality both regional and international in scope. The SIUs and investigative agencies identified individuals suspected of defrauding workers’ compensation insurers, but due to the complexity and variety of schemes, and the plethora of players, successful interdiction was beyond any one entity. Participants in this session will learn about the complexities of this case and the potential threats to their own organizations.

Jeffrey B. Horner
Special Agent, U.S. Dept. of Justice, Federal Bureau of Investigation

Valerie Chu
Assistant United States Attorney, United States Attorney's Office, Southern District of California

Israel Garcia
Detective, California Department of Insurance, Fraud Division

Roger Gutierrez
SIU Investigator, The Hartford

LEGAL, MANAGEMENT AND COMPLIANCE ISSUES

 

Top Legal Issues in Health Care Fraud
WEDNESDAY, NOVEMBER 16 | 9:45 am - 10:45 am
Level I

This session will offer an overview of the most important emerging anti-fraud legal and regulatory developments including recent state and federal court decisions, federal regulatory actions and interesting legislative initiatives. The faculty is an attorney working with the health insurance industry on key legal issues and will examine topics including prescription drug coverage, claims under Medicare Part D, clinical lab fraud, and government use of sampling/extrapolation. In addition, our faculty will discuss the use of the SEC whistleblower program and SEC focus in health care fraud investigations/ prosecutions.

Jeremy Sternberg
Partner, Holland & Knight, LLP

Preparing for a CMS Audit
WEDNESDAY, NOVEMBER 16 | 11:00 am – 12:00 pm
Level II

The SIU of Medicare Advantage plans must implement measures to prevent, detect, and correct fraud, waste, and abuse. Session will provide guidance on SIU specific activities every MA plan should be doing and assist when the SIU is audited. Insights, lessons learned and recommendations from a recent CMS audit of a health plan.

Lisa Jensen, MHBL, FACMPE, CPC
Sr. Manager of External Audit (SIU), Providence Health Plans

Lynn O’Dea
Director, Special Investigations – Government Programs Department, Health Care Service Corporation

Melissa Lupella
Director, Government Programs Compliance, Health Care Service Corporation


Where Are You Vulnerable? Conducting an Effective Healthcare Fraud-Focused Risk Assessment
WEDNESDAY, NOVEMBER 16 | 2:15 pm - 3:15 pm
Level II

Every effective fraud prevention and detection system must start with an identification and analysis of fraud risk factors, fraud risks, and a quantification of those risks. Conducting a fraud risk assessment can help entities and programs identify those risks for which their programs are most susceptible so resources can be most effectively managed to prevent, detect, and respond to fraud. This presentation will inform participants of the advantages, and in some cases requirements, driving the need to conduct a fraud risk assessment, as well as provide an overview of how to effectively conduct a healthcare focused fraud risk assessment as a way to help any entity/organization/program prevent, detect, and respond to fraud.

Timothy Hedley, MD
Partner, KPMG, LLP

Meghan Hendery
Director, KPMG, LLP

Jesse Morton
Director, Federal Fraud Risk Management, KPMG, LLP

Tips for SIUs on Making Successful Law Enforcement Referrals
WEDNESDAY, NOVEMBER 16 | 3:25 pm – 4:25 pm
Level II

The presenters will review and discuss the types of investigations to consider referring to law enforcement and how to select the appropriate agency to refer the matter. The participants will learn best practices in formatting and packaging investigations for referral. Presenters will take the participants from case referral through prosecution and discuss the ongoing support required of SIU investigators and analysts. During the presentation, the participants will hear about real cases that were referred to law enforcement and successfully prosecuted. The presentation will include a discussion in which participants will be asked to share best practices in regard to law enforcement referrals.

Tamara Neiman
Director, Special Investigations Unit, Kaiser Permanente

Daniel Falzon
Senior Manager, Special Investigations Unit, Kaiser Permanente

ERISA Pre-emption: Recovering Overpayments
WEDNEDAY, NOVEMBER 16 | 4:30 pm – 5:15 pm
Level I

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. Hear a basic overview of ERISA, its equitable remedies and its relationship to state insurance laws. Our speaker 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 these new theories. Gather tips on framing your overpayment recoveries to avoid this challenge.

Carolyn Ham, Esq., AHFI

Applying Advanced Analytics to Combat & Prevent Healthcare Fraud
THURSDAY, NOVEMBER 17 | 10:30 am – 11:30 am
Level II

Analysts and data scientists are giving their organizations an edge by applying predictive analytics on claims, application/enrollment information, and other big data to combat and prevent healthcare fraud. Have you wondered what the difference really is between outlier analysis and predictive modeling and the benefits of each? And what does a correlation analysis really mean? This primer for advanced analytics will spotlight the specific methods used by data analysis experts in the fraud fight including sampling, correlation, feature extraction, regression and modeling. Methods and tools will be discussed with a universal perspective, as companies and SIUs often use a variety of analytical platforms and vendors.

Douglas Rahden, CPMA
Informatics Senior Specialist, SIU Core Analytics, Cigna

Jason DiNovi, CPMA
Informatics Senior Specialist, SIU Core Analytics, Cigna

Preparing for TrialLEL Path
THURSDAY, NOVEMBER 17 | 1:00 pm – 2:00 pm
Level I

Trial preparation begins from the moment the case is assigned. What steps should you take to ensure that you have prepared for a trial? This session, led by an expert prosecutor, offers insight into how to plan, enter findings, create and prepare exhibit summaries, and develop witness files. By hearing from an attorney, participants will be able to think about how they approach their work and be better prepared to work an investigation.

Nancy B. Allstrom
Senior Assistant Attorney General, Georgia Medicaid Fraud Control Unit

Management Roundtable Discussion - Part I & II
THURSDAY, NOVEMBER 17 | 2:15 pm – 4:30 pm
Level III

A combination of networking and education, this high energy session features interactive roundtable discussion of SIU management topics faced by unit leaders. The format encourages participants to move from topic area to topic area to engage in open, creative conversation on best practices and problem solving experiences, to make new connections, and to share knowledge.

Ralph J. Carpenter
Senior Director, SIU, Aetna

Jonnie Massey, CPC, CPC-P, CPC-I, CPMA, AHFI
Director, SIU, Blue Shield of California

Richard Munson, AHFI
Vice President, Investigations, Unitedhealthcare Investigations

Roger I. Purnell, AHFI, CFE
Manager, SIU, Blue Cross Blue Shield of North Carolina

Health Care Fraud Investigator Ethics Workshop
FRIDAY, NOVEMBER 18 | 9:30 am – 11:30 am
Level II

Two premier health care anti-fraud compliance instructors lead a 2-hour seminar on professional and investigative ethics for the health care fraud investigator. The program will combine lecture with group discussion and will focus on practical ethical challenges faced by investigators in the areas of evidence, interviewing, professional and business activities, privacy, as well as review legal and regulatory requirements. This course is designed to meet the American Certified Fraud Examiner CFE ethics training requirement.

Darrell S. Langlois, CPA, CIA, AHFI
Vice President, Compliance, Privacy & Fraud, Blue Cross Blue Shield of Louisiana

Nicholas J. Messuri, Esq.,
Vice President, Fraud Prevention & Recovery, DentaQuest

FRAUD ISSUES IN FEDERAL AND STATE PROGRAMS

 

The Final HHS Rule to Modernize Medicaid Managed Care: Examining the Effects on Health Care Fraud
WEDNESDAY, NOVEMBER 16 | 9:45 am - 10:45 am
Level II

Earlier this year, the Department of Health and Human Services (HHS) issued its Final Rule aimed at overhauling and modernizing regulatory oversight of managed care in both Medicaid and the Children’s Health Insurance Program (CHIP)—the first in more than a decade. Numerous provisions in the Rule impact the ability of state programs and private insurers to fight health care fraud, including changes to compliance program requirements, suspension of payment requirements and provider screening responsibilities. Hear from thought leaders working to implement the new Rule at the state level about the new challenges and opportunities created by the Rule.

Clint Eisenhower
Director, State Liaison Staff, Governance Management Group, Center for Program Integrity, Centers for Medicare & Medicaid Services

John Maynard, CPA
Program Integrity Director, Ohio Department of Medicaid

Valerie Smith
Staff Attorney, Medicaid Fraud Control Unit of Tennessee, Bureau of Investigation

CMS Update: Initiatives and Progress in Health Care Fraud
WEDNESDAY, NOVEMBER 16 | 11:00 am – 12:00 pm
Level II

Hear from leadership at the Centers for Medicare and Medicaid Services (CMS) about the ongoing efforts to coordinate with Federal and state partners, as well as the private sector, to identify fraud trends and patterns. Participants will gain a better understanding of the successes to date and the future promise of the Healthcare Fraud Prevention Partnership (HFPP) and the Fraud Prevention System which are helping to uncover fraudulent schemes and trends in new ways.

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

Strategies for Coordinating between MFCU, MPIs and MCOs for Strong and Appropriate Enforcement Actions
WEDNESDAY, NOVEMBER 16 | 2:15 pm - 3:15 pm
Level II

As a result of the expansion of Medicaid and the recently finalized Medicaid Managed Care rule, the need to create a consistent approach to fight fraud between the Medicaid Program Integrity (PI), Medicaid fraud control units (MFCUs), and Medicaid Managed Care Organizations (MCO) has become even more critical to fighting health care fraud. Hear from leaders from the public and private sectors about best practices in communication, successful referrals, and effective cooperation. Through an interactive discussion, our faculty will offer their perspectives on how to share claims data, billing and provider data between MCO SIUs and the state.

Nicholas J. Messuri, Esq.,
VP, Fraud Prevention & Recovery, DentaQuest (moderator)

Katherine Leff, RN, ALHC, CLU, AHFI, CPC, CFE, CHC
Director, Special Investigations Unit, CareSource Management Group

William A. Falk
Deputy Chief Investigator, New York State Office of the Attorney General, Medicaid Fraud Control Unit

John. F. McCormick, CPA
Director, Office of Quality Assurance, Connecticut Department of Social Services

Home Health and Hospice
WEDNESDAY, NOVEMBER 16 | 3:25 PM - 4:25 PM
Level II

CMS will present an update on the models and investigative strategies used for investigation of home health and hospice. The speakers from CMS will also present the four major hospice vulnerabilities and present information on how CMS identifies leads to target for investigation. The presentation will focus on best practices used by AdvanceMed ZPIC Zone 5 and outline the integrated team approach using analysts from data, medical review, program integrity, and subject matter experts who coordinate efforts to appropriately target investigations. This team presentation will outline and discuss the significance of this multifaceted approach early and throughout the investigation. Attendees will gain insights on medical review tips, cluster analysis of home health and hospice providers and, the use of administrative actions (pre- and post-pay reviews, suspensions, revocations, exclusions).

Fernando Alvarez, JD
Director, Division of Field Operations-South, U.S. Dept. of Health & Human Services, CMS

Rebecca Clearwater, PT, MS, DPT
NCI AdvanceMed Corporation

Horace Dozier
Deputy Director of the Division of Provider Investigations & Audits, U.S. Dept. of Health & Human Services, CMS

Angela M. Newton, CFE
NCI AdvanceMed Corporation

Interviewing the Frail and Elderly
WEDNEDAY, NOVEMBER 16 | 4:30 pm – 5:15 pm
Level I

Elderly require special approaches and an understanding of their physiological well-being during the interview process. What considerations need to be taken before and during the interview process to ensure valuable information is obtained? In this session, our speaker will provide attendees with insights and perspectives that will be valuable to attendees including assessing a person’s capacity and competency.

Maritsa A. Flaherty
Senior Assistant Attorney General, Health Care Fraud Section, Office of Ohio Attorney General Mike DeWine

Carrie Jo Meads
Chief Investigator, State of Nevada Medicaid Fraud Control Unit

Whistleblowing and the False Claims Act -- The Other Public-Private Partnership
THURSDAY, NOVEMBER 17 | 10:30 am – 11:30 am
Level I

The civil False Claims Act (FCA) is the Government's primary tool for combatting fraud and returning stolen taxpayer funds to the Treasury. This law -- and all of its state counterparts -- also includes a qui tam, which authorizes private persons (whistleblowers) to sue on the Government's behalf in exchange for financial rewards. The overwhelming majority of all FCA suits are filed by whistleblowers and concern fraud on federal and state healthcare programs. NHCAA members are uniquely-positioned to make use of FCA laws, given their expertise in investigating and exposing healthcare fraud and their strong relationships with Government fraud-fighters. This session is designed to encourage increased cooperation and coordination between and among NHCAA members and their Government partners, by focusing on the civil remedies available when the Government falls victim to healthcare fraud, as well as the financial rewards available to those who help the Government recover its money.

Cleveland Lawrence
Of Counsel, Whistleblower Director, Sanford Heisler, LLP

Jennifer M. Verkamp
Partner, MorganVerkamp LLC

Matthew K. Organ
Principal, Goldberg Kohn LTD

The Aftermath of the Supreme Court’s Decision on the So-Called “Implied Certification” Case
THURSDAY, NOVEMBER 17 | 1:00 pm – 2:00 pm
Level II

Universal Health Services Inc. v. US ex rel. Escobar was the biggest legal challenge since the 1990s to the False Claims Act, the government’s principal weapon against healthcare fraud. The Supreme Court’s decision in the case earlier this year will be felt by all healthcare providers and will impact compliance and enforcement of Medicare Advantage, Medicaid Managed Care and Part D plans. The case addressed whether a Medicaid provider’s request for payment must contain a literally false statement to trigger liability under the False Claims Act and whether only violation of a statutory, regulatory or contractual requirement that is expressly designated as a condition of payment can give rise to liability. The panel also will explain the impact of comments the Court made in its decision about the Act’s requirements that a misrepresentation be “knowingly” made and “material” to the government’s decision making. The panelists – a former top CMS official and a whistleblower attorney – will provide their perspectives on the decision and a robust discussion of the issues.

Peter Budetti, JD, MD
Former Deputy Administrator, Centers for Medicare and Medicaid Service, and Of Counsel, Phillips & Cohen LLP

Claire M. Sylvia
Partner at the whistleblower law firm, Phillips & Cohen LLP, and the author of The False Claims Act: Fraud Against the Government, a leading treatise on the law.

The Rise of Fraud in Home Health Care Services: A Case StudyLEL Path
THURSDAY, NOVEMBER 17 | 2:15 pm – 3:15 pm
Level I

According to a 2010 study, Medicare inappropriately paid $5 million for home health claims. Hear from agents who worked the case of Dr. Roy who approved and certified excess of 11,000 Medicare beneficiaries for home health care services between January 2006 and August 2011. Dr. Roy was the certifying physician for approximately 500 different home health agencies. Dr. Roy certified patients for home health care who were not homebound and/or were illegally solicited by patient recruiters. Total billing to the Medicare program both directly and indirectly by Dr. Roy and his co-conspirators was estimated to be in excess of $375 million. In April 2016, Dr. Roy and his co-conspirators were convicted after a six week trial of conspiracy to commit health care fraud. This investigation was worked jointly with FBI, HHS-OIG and the Texas Attorney General’s Medicaid Fraud Control Unit.

Miranda Bennett, ASAC
Special Agent, U.S. Department of Health & Human Services, Office of the Inspector General

Chelsie Drews
Special Agent, U.S. Department of Justice, Federal Bureau of Investigation

Phillip Meitt
Assistant United States Attorney, Northern District of Texas

Tools, Techniques, and a Case Study Illustrate Medicare Part C InvestigationsLEL Path
FRIDAY, NOVEMBER 18 | 9:30 am – 11:30 am
Level I

In this two-part workshop, attendees will learn specific investigative methods and tools used in Managed Care- Part C health care fraud investigations. Participants will learn data analysis techniques needed in Managed Care - Part C health care fraud investigations and gain a better understanding of how to work the health care plan.

In part one, the presenters will review and discuss detailed techniques for identifying and investigating the extent to which physicians may be up-coding and how much money they are receiving as a result. Specific techniques include but are not limited to data analysis using encounter data, identifying and understanding cpt codes, working with the health care plan, and calculating monetary loss.

Wende Bardfeld
Special Agent, U.S. Department of Justice, Federal Bureau of Investigation

E. Nesbitt Kuyrkendall
Special Agent, U.S. Department of Justice, Federal Bureau of Investigation

Amber Meurs
Special Agent, U.S. Department of Health & Human Services, Office of the Inspector General, Greater Palm Beach Health Care Fraud Task Force

Jennifer Minton
Intelligence Analyst, U.S. Department Justice, Federal Bureau of Investigation

In part two, attendees will hear about the case of Florida Healthcare Plus (FHCP), a Medicare Part C Advantage Plan, and international Medicaid Advantage fraud scheme. The plan, based in Miami, Florida, by and through several of its providers targeted American Citizens living abroad, that had a valid Medicare card with options A & B active, to join a specific Part C plan providing medical services in the foreign country where they were residing.

Radu Pisano
Special Agent, Special Agent, U.S. Department of Health & Human Services, Office of the Inspector General

Fernando Porras
Special Agent, U.S. Department of Health & Human Services, Office of the Inspector General

FRAUD IN SPECIALTY AREAS // LTC, WORKERS' COMP AND DI

 

Fraud Surveillance Strategies for Long Term Care and Disability Products
WEDNESDAY, NOVEMBER 16 | 9:45 am – 10:45 am
Level II

Surveillance is a critical part of many investigations. Attendees will learn the steps to properly implementing a strategy from the “pre-surveillance” check and checking social network activity to appropriately budgeting resources, and planning and scheduling in person surveillance. Experts from the field will provide their insights and thoughts on how to effectively prepare for surveillance activities.

Patrick K. Burke, CFE, CIFI, FCLS
Director of Investigations, The Robison Group

Roger Kooi
Special Investigations Unit, MetLife Auto & Home Group

Dentistry Fraud Basics from Procedures to Treatments and Red Flags
WEDNESDAY, NOVEMBER 16 | 11:00 am - 12:00 pm
Level I

This session will review the basics of dentistry. Descriptions and visual aids of dental procedures to better understand these procedures. How to recognize information from a dental claim that may indicate fraud and abuse and case examples of dental treatment and progression of treatments that are red flags for abuse and fraud will be presented. At the end of this presentation, participants will be able to review a dental claim and evaluate the information on that claim.

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

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

Dental Providers: The Potential for Coding Abuse
WEDNESDAY, NOVEMBER 16 | 3:25 pm – 4:25 pm
Level III

Dental providers across the country pose a unique challenge for governmental and private payer audits. Dentists, unlike other providers, may bill both dental benefits plans and medical benefits plans. A dentist may bill a dental plan using CDT codes. A dentist may bill a medical plan using CPT, HCPCS, and CDT codes. Recent billing issues uncovered include: upcoded radiographs from dental to medical and 'cloaked' endodontic, periodontics, prosthodontics, orthodontics, cosmetic and falsified orofacial trauma diagnoses and services billed to medical under incorrect or misleading CPT codes. Participants will gain insight on which codes are abused and tools used so that more comprehensive data sharing may occur between two plans within the same company, leading to better outcomes in dental provider audits.

Amy Krakower, Esq., JD, CCP
Senior Investigator, SIU, Anthem, Inc.

Mary Morales, RDH, MHSA
Senior Investigator, Dental SIU, Anthem, Inc.

Dental Directors’ Quick Hits Panel
THURSDAY, NOVEMBER 17 | 10:30 am – 11:30 am
Level II

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.

Stewart Balikov, DDS, AHFI
National Dental Director Utilization Management, Aetna (moderator)

Mary Jo Blank, RDH
Director, Fraud Prevention & Recovery, DentaQuest

Kay Eckroth, DDS, AHFI
Dental Director, Aetna

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

Using Analytics in Fraud and Abuse Detection in Worker’s Compensation
Thursday, November 17 | 1:00 pm - 2:00 pm
Level II

Fraud and abuse problems in worker’s compensation insurers are significant, and can benefit from analytics programs to help detect bogus injury claims, malingering and scope creep, fraudulent medical providers, and premium avoidance scams. The presenters in this session will examine how analytics can help to uncover scams which can be hard to identify in growing caseloads. How to identify the most valuable data, how to apply analytics and how to integrate data will be key areas of discussion among these experts.

Carl Hammersburg
Manager, Healthcare and Government Fraud, SAS

Ben Wright, AHFI, CDP
Senior Solutions Architect, SAS

Cross-Border Dental Fraud
THURSDAY, NOVEMBER 17 | 2:15 pm – 3:15 pm
Level II

The presenter will provide detailed information regarding current schemes being utilized by Mexican medical/dental provider to defraud US insurance carriers and government sponsored plans. Attendees will be exposed to case studies that demonstrate current fraudulent tactics and be presented with samples of fraudulent facturas (receipts) and examples of legitimate documents sanctioned by the Mexican government. Attendees will also learn about current legal tactics being utilized by US based billing agencies that are taking legal action in US courts against policy holders in an effort to pressure US insurance carriers to pay claims. The presenter will also provide detailed information that will assist insurance company anti-fraud staff determine legal standing on the part of US based billing agencies to demand payment of claims for services rendered outside the US by foreign providers.

Joaquin Basauri
Senior Investigator, Kaiser Permanente

Dental Fraud Schemes in the Commercial & Public Sector
FRIDAY, NOVEMBER 18 | 9:30 am – 11:30 am
Level II

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 AHFI Dental Directors.

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

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

ANTI-FRAUD SOLUTIONS

 

Identifying and Building a Strong SIU Case
WEDNESDAY, NOVEMBER 16 | 9:45 am – 10:45 am
Level II

Presented by Verscend, an NHCAA Platinum Supporting Member

How much time does your SIU spend researching and investigating leads that turn out to be false positives or don’t hold up to law enforcement’s requirements for proof? In order to reduce false positives and deploy their resources efficiently and effectively, the SIU utilizes “turnkey allegations,” or ready-to-investigate case referrals that have been vetted by an investigative team before the SIU receives them. Using recent examples of fraud schemes and abuse patterns, the presenters will first discuss their processes of identifying true-positive outlier billing behavior and building the pre-case burden. They’ll finish by discussing the SIU steps involved with investigating a turnkey allegation.

Joe Christensen, AHFI
Director, Special Investigations Unit, Aetna

Ryan Cleverly, AHFI
Director of SIU and Fraud Operations, Verscend

It’s Not Just Fraud: Innovative Approaches to Visualizing and Addressing Payment Vulnerability Across the Organization
WEDNESDAY, NOVEMBER 16 | 9:45 am – 10:45 am
Level II

Presented by Change Healthcare, an NHCAA Platinum Supporting Member

Fully addressing organizational payment risk is not limited to fraud in the Special Investigations Unit. The new era of healthcare delivery highlights the need for a single source of truth to identify payment vulnerability across multiple areas such as SIU, Medical Informatics, Claims Operations and Network Management. The changing landscape requires clear view into your payment vulnerabilities, not just the ones you are looking for. Once identified, the ability to quickly select and deploy the best course of action for the specific identified risk is key. Learn more about innovative ways to combine data sources, develop risk based visualization and quickly select the best resolution methods from multiple options, to address each identified risk.

Chris Hall, HCAFA
Director of Operations, Payment Integrity, Change Healthcare

Will O’Neill
Director, Product Management, Change Healthcare  

Commanding the Power of an End-to-End Program Integrity Approach to Intercept and Defend Against Inappropriate Payments
WEDNESDAY, NOVEMBER 16 | 11:00 am -12:00 pm
Level II

Presented by General Dynamics Health Solutions, an NHCAA Platinum Supporting Member

To protect patients and the bottom line, health payers must maintain strong, consistent program integrity efforts. Implementing a comprehensive program integrity solution that fully integrates essential Special Investigations Unit services and effective anti-fraud technology can help prevent improper payments and increase recoveries. In this session, participants will learn strategies for creating effective pre-pay prevention and post-pay detection programs. In addition, participants will gain valuable insights into supporting efforts to detect, prevent and respond to fraud, waste and abuse. Actual case examples will be presented, to include successful post-payment initiatives (including service verification and pharmacy lock-in programs).

Jessica Gay, CPC, AHFI
Service Delivery Manager, Health Solutions’ Program Integrity Services, General Dynamics Health Solutions

Erin Picton, AHFI, CFE
Manager, Investigations, Health Solutions’ Program Integrity Services, General Dynamics Health Solutions

Mark Starinsky, CFE, AHFI
Service Delivery Manager, Health Solutions’ Program Integrity Services, General Dynamics Health Solutions

Addressing Evolving Threats in Fraud, Waste and Abuse – Innovations and Insights
WEDNESDAY, NOVEMBER 16 | 11:00 am -12:00 pm
Level II

Presented by Truven Health Analytics, and IBM Company, a NHCAA Platinum Supporting Member

Discover the latest innovations in fighting fraud, waste, and abuse in a managed care environment, including predictive analytics, algorithms, oversight and reporting. Best practices will be shared on closing the gap between needing to reduce waste and abuse in the managed care environment — and the ability to do so successfully and cost-effectively while ensuring MCOs actively engage in program integrity. Additionally, attendees will learn about new fraud schemes and trends, and technical and analytic detection approaches that work.

Jean MacQuarrie
Vice President, Payment Integrity Solutions, Truven Health Analytics, an IBM Company

David Nelson
Vice President, Market Planning & Strategy, Truven Health Analytics, an IBM Company

Mark Gillespie
Vice President, Government Solutions Management, Truven Health Analytics, an IBM Company

Dennis Garvey, JD, BA
Director Consulting, Truven Health Analytics, an IBM Company, and former Program Integrity Director for the state of Tennessee

How Analytics Helps BCBS of Michigan Find and Stop Fraud Faster
WEDNESDAY, NOVEMBER 16 | 2:15 pm – 3:15 pm
Level II

Presented by SAS, an NHCAA Platinum Supporting Member

Find out how Blue Cross Blue Shield of Michigan – the state’s largest health insurer, serving 4.5 million people in-state and an additional 1.6 million in other states – is working with SAS to detect, prevent and manage fraud, waste, and abuse. You’ll learn how the SAS® Fraud Framework uses a hybrid analytical approach to help BCBSM transform vast amounts of data from multiple sources into actionable results that find and stop fraud faster. Predictive modeling and network analytics comb seemingly isolated events to spot hidden connections, patterns and anomalies – saving precious time and resources along the way. We’ll review specific case studies where initial data leads evolved into in-depth investigations with substantial findings.

Shawn Salkeld
Healthcare Payment Integrity Lead, SAS

Paul Welch
Manager of Advanced Analytics, Blue Cross Blue Shield of Michigan

Modifiers: Changing the Game
WEDNESDAY, NOVEMBER 16 | 2:15 pm – 3:15 pm
Level II

Presented by Healthcare Fraud Shield, an NHCAA Platinum Supporting Member

Digging into common and not so common modifiers that impact various aspects of services billed including payment and description of the service. Learn the latest schemes involving modifiers -26, -50, 90, 91 and more! Explore the different techniques on how to detect suspect claims and providers in your analytics, what information to ask for when verifying services and resources to assist you in your investigation. Healthcare Fraud Shield will facilitate the learning through real case examples.

Kathleen Shaker, BSN, RN, CPC, CPC-H, AHFI
FWA Subject Matter Expert, Healthcare Fraud Shield

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

Tony Rademeyer, MBA
Executive Vice President, Healthcare Fraud Shield

Technological Innovation and the 21st Century SIU
WEDNESDAY, NOVEMBER 16 | 3:25 pm – 4:25 am
Level II

Presented by CGI Federal Inc., an NHCAA Platinum Supporting Member

Are you ready for the quantum shift in healthcare delivery and finance, and do you understand how technology will enhance and change the role of the SIU? Only when all current and historical data points are simultaneously considered, will the full scope and power of audit be realized across the enterprise. New innovations in machine learning, data visualization, geospatial analysis, cloud computing, and predictive modeling enable a much more thorough identification of trends and patterns in fraud, waste, or abuse than has been historically possible. Learn how the latest in healthcare payer technology can refine your audit capabilities and help you manage the quantum shift occurring in healthcare finance.

Rob Rolf
Vice President, Healthcare Compliance, CGI Federal Inc.

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

Advanced Predictive Analytics Explained
THURSDAY, NOVEMBER 17 | 7:45 am – 8:45 am
Level II

Presented by BAE Systems, an NHCAA Premier Supporting Member

When it comes to combatting healthcare fraud with predictive analytics, it’s not uncommon to hear it touted, without any additional information or explanation. Additionally, some in the industry say they offer or conduct predictive analytics, when in actuality, it’s rule based analytics. In this session, BAE Systems will explain the complex predictive analytic methods in a relatable way, and provide examples of the types of schemes typically identified. Some of the analytics we will discuss include: Classifications, Clustering, Outliers, Feature Relevance/Reductions, Statistical Optimization, Evolutionary Optimization, Big Data Learning, automated drift detection and correction.

Tristan Spoor
NetReveal Technical Lead, BAE Systems Applied Intelligence Inc.

Community-Based Innovation to Combat Fraud: The Health Care Fraud Grand Challenge
THURSDAY, NOVEMBER 17 | 7:45 am – 8:45 am
Level II

Presented by The MITRE Corporation, an NHCAA Premier Supporting Member

Courses specific to health care fraud analytics are scarce in most undergraduate and even graduate programs. As fraudsters continue to attack using increasingly sophisticated schemes, we need creative white hats to counter and anticipate their efforts. Following the model of other public IT challenge competitions, the Health Care Fraud Grand Challenge encourages universities and institutions to form academic teams to compete, building algorithms to solve complex fraud challenges and testing innovative ideas that will be assessed by industry experts. Hear more about the Challenge timeline and how to join.

Rob Case
Chief Scientist for Analytics, The MITRE Corporation

Amber Fee, AHFI, CPC
Principal Health Care Fraud Risk Analyst, The MITRE Corporation

Sanith Wijesinghe
Principal Information Systems Engineer, The MITRE Corporation

Leveraging Analytics and Advanced Profiling to Predict and Prevent FWA
THURSDAY, NOVEMBER 17 | 7:45 am – 8:45 am
Level II

Presented by SCIO Health Analytics, an NHCAA Premier Supporting Member

With the growing complexity of healthcare reimbursement and the rise of inappropriate healthcare expenditures, the time is now to leverage data and analytics to enhance FWA programs and processes. This session will discuss the need to progress beyond claim level analysis for FWA and the importance of leveraging predictive analytics, member and provider profiles and rich multi-source data to identify FWA patterns, reduce errors, limit false- positives and improve overall performance recoveries. Leaders from SCIO Health Analytics will share exemplars and best practices related to the use of advanced predictive modeling, data benchmarks and clinical expertise to identify true outliers. Focus areas will include incorporation of member risk, socioeconomic and behavioral data, billing patterns, utilization and quality indicators in conjunction with claims analysis. Relevant use cases including the applicability to the growing challenge of FWA in opioid abusers will be reviewed.

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

Rodger Smith
SVP Payment Integrity, SCIO Health Analytics

Lalithya Yerramilli
SVP Healthcare Data Analytics, SCIO Health Analytics

Schemes and Scams - Costing Americans Billions of Dollars Annually
THURSDAY, NOVEMBER 17 | 7:45 am – 8:45 am
Level II
Presented by Tricast, a NHCAA Platinum Supporting Member

Inappropriately compounded drugs were the FWA poster child of 2015. Opioid fraud and abuse has evolved into a crisis of epidemic proportions, and many health plans continue to bleed resources due to wasteful behavior. And the future? How do you look for the next big prescription drug scam? Ever wonder if you could find and investigate a scheme before it hurts your bottom line? Greg Rucinski, CEO of TRICAST (and licensed pharmacist), shares his views on the past, present and future of prescription drug FWA monitoring.

Greg Rucinski
President & CEO, Tricast

Fraud Alliance: A case study on data aggregation to combat fraud
THURSDAY, NOVEMBER 17 | 7:45 am – 8:45 am
Level II

Presented by Optum, an NHCAA Platinum Supporting Member

The presentation will describe Optum’s Fraud Alliance, a fraud and abuse tool that aggregates data from multiple participating managed care organizations to provide enhanced fraud and abuse leads and insight. The data and analysis arising from this data aggregation provides significant case value and analytic value as compared to the data and analysis of a single managed care organization. The Alliance is two-pronged, focusing on: (1) pre-pay analytic claims scoring; and (2) existing case comparison.

Lee Arian
Optum, Vice President, Optum, Program Integrity Consulting Group

The New Menace: FWA on the Marketplace Exchange & Organized Crime
THURSDAY, NOVEMBER 17 | 10:30 am – 11:30 am
Level II

Presented by LexisNexis, an NHCAA Platinum Supporting Member

The Affordable Care Act and the expansion of Marketplace Exchanges has laid the foundation for more consumers to attain health benefits. Despite the positive impacts of these initiatives, they both allow for an influx of identity and organized crime to drain more dollars from an already strained health care system. The potential for a distressing percentage of brokers to drain millions from insurers by enrolling non-existent, deceased and otherwise ineligible individuals exists. This session will explore the realities of identity-based and organized fraud schemes hidden in vast amounts of claims data only visible with the right combination of analytics.

Mark Isbitts
Director Payment Protection Solutions, LexisNexis

Tom Figurski
Manager FWA, LexisNexis

Collaboration in the Vendor-Client Relationship for Pharmacy Audit
THURSDAY, NOVEMBER 17 | 10:30 – 11:30 am
Level II

Presented by Xerox, an NHCAA Platinum Supporting Member

An all hands approach to program integrity should be the gold standard, but goal-alignment and collaboration may be elusive. And what is the value of convergent analysis? Join experts from Xerox Audit & Compliance Solutions and Humana Pharmacy Solutions as we discuss convergent and collaborative analysis within a client-vendor relationship, and its place in Humana’s multi-pronged approach to network integrity. Our experts will use several case examples to highlight how independent analysis has led to stronger cases against suspect pharmacies, and how information sharing has led to scrutiny of other suspect behavior.

Joshua Peters, PharmD, RPh
Lead FWA Auditor, and Account Manager, Xerox Audit & Compliance Solutions

Brian Wehneman, RPh
Director, Office of Pharmacy Fraud, Waste & Abuse and Prevention, Humana Pharmacy Solutions, Inc.

Are South African Fraud Schemes Coming to America?
THURSDAY, NOVEMBER 17 | 1:00 pm – 2:00 pm
Level II

Presented by FICO, an NHCAA Platinum Supporting Member

AfroCentric, one of the largest healthcare payer administrators in South Africa will discuss how they revamped their fraud program and used the universal language of mathematics to transcend cross-cultural differences. Attendees will learn how and why AfroCentric modified their fraud program and important strategies for success and how using “out of the box” predictive analytics to address fraud, waste and abuse was extended to a consortium environment. Our presenter will explain how they determined and detected that 14% of their revenue waste was fraud; and when these schemes might hit the U.S.

Paul Midlane
General Manager – Legal, Forensics & Compliance, AfroCentric Health

Paul Crowder
Pre-Sales Consultant, FICO

Painful Price, Potential Promise: Using Analytics to Combat Compound Rx Fraud
THURSDAY, NOVEMBER 17 | 1:00 pm – 2:00 pm
Level II

Presented by HMS, an NHCAA Platinum Supporting Member

Tricare paid out $1.75 billion for compounded drugs in 2015, which was 18 times the amount that they paid just three years ago. Our health care system has left the door open for these high price tags and for patient recruiters or marketers to convince patients of miraculous cures. In this session, attendees will learn the latest scams in compounded pharmaceuticals, analytic methods to identify investigative targets and build cases, and how to work with pharmacy benefit managers to fight fraud.

Bill Mahon
President, The Mahon Consulting Group LLC

Jean Lyon, RN, MS
Vice President of Innovation, HMS