Conference Sessions

Behavioral Health and Substance Abuse Fraud Issues
Expanding Your Investigative Skills
Pharmacy and Opioid Schemes
Case Studies to Address Trending Schemes in Health Care Fraud
Emerging Trends in Health Care Fraud
Dental Fraud Schemes
Seminars
Anti-Fraud Solutions

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Behavioral Health and Substance Abuse Fraud Issues

Basics of Autism Reviews
Tuesday, October 30
10:00 am – 11:00 am
Level 101

Billing for autism services is relatively new in the insurance world. State mandates regarding coverage for autism services have changed insurance companies' relationships with autism providers. In order to understand the billing patterns of autism providers, investigators first need to understand autism itself and how it is treated. Once investigators have a better understanding of the disorder, then they will be able to better identify appropriate treatment and billing patterns of providers.

This presentation will assist investigators in:

  • Understanding what is the Autism Spectrum Disorder and the appropriate treatment protocol
  • Determinng the red flags with data mining Applied Behavior Analysis (ABA) services
  • Recognizing how ABA services are documented and how to interpret them

Faculty

Jill Carraher, LMSW, AHFI
Manager, Claims Integrity, New Directions Behavioral Health

Amanda Brown, MBA, AHFI
Compliance, Vice-President, New Directions Behavioral Health

Levels of Intensity for Behavioral Health Services
Tuesday, October 30
11:15 am – 12:15 pm
Level 101

There are multiple levels of care in behavioral health services, including outpatient, intensive outpatient, partial hospitalization, residential and inpatient services. Without having previous experience with or knowledge of behavioral health services, it can be challenging for investigators to know what the appropriate levels of care are due to the variety in mental health disorders and how they are treated.

This presentation will assist investigators in:

  • Recognizing treatment protocols provided at each level of care, including outpatient, intensive outpatient, partial hospitalization, residential and inpatient
  • Determing red flags when data mining behavioral health services at each level of care
  • Examining the type of information is in behavioral health medical records and how to review the records?

Faculty

Jill Carraher, LMSW, AHFI
Manager, Claims Integrity, New Directions Behavioral Health

Deepak Rajpoot, MD
Medical Director, New Directions Behavioral Health

Behavioral Health and Substance Abuse Fraud Schemes and Trends: A Clinician's Perspective
Wednesday, October 31
10:45 am – 11:45 am
Level 201

With the Affordable Care Act, Mental Health Parity, and the opioid epidemic, mental health care has become increasingly prevalent. Presenters will provide an overview of common fraud schemes in behavioral health treatment. Fraud schemes that will be discussed will include, but are not limited to, psychotherapy add-ons to evaluation and management services, interactive complexity, and individual and family psychotherapy. Mock medical records will be reviewed in order for participants to gain knowledge on identifying red flags in documentation, which will in turn assist participants with determining which types of investigations would be clinically relevant.

This presentation will assist investigators in:

  • Recognizing common behavioral health fraud schemes
  • Determining what is clinically relevant and how it relates to data
  • Reviewing specific schemes and codes that are often misused as well as documentation errors commonly seen

Faculty

Jessi Clark, LMHC
Clinical Supervisor, SIU, Centene

Courtney Reed, LPC
Clinical Reviewer, SIU, Centene

Identifying Trends in Applied Behavior Analysis (ABA) Therapy
Wednesday, October 31
1:55 pm – 2:55 pm
Level 201

Data Analysts and Investigators will learn about the definitions of key terms around ABA therapy, Autism and data analysis. The presentation will follow how the data was first identified, analyzed and investigated by SIU. Attendees will learn about the outcome and coordination of the investigations that led to a new company policy being implemented to prevent FWA in this space. The last portion of the presentation will focus on new and emerging schemes from providers who are attempting to bypass the new policy. The faculty will demonstrate the importance of internal collaboration which can led to policy changes and financial recoveries in addition to fraud referrals.

This presentation will assist investigators in:

  • Understanding autism CPT and diagnosis codes and their frequency limitations
  • Recognizing and determining how to data mine for excessive units billed and research state limitations

Faculty

Sarah Essing
Manager, Humana

Laura Wilford
Manager, Humana

Sarah Butler, MBA, CFE
Manager, Overpayments, Solutions & Opportunities (OSO), Claims Cost Research & Opportunity, Humana

Mental Health Case Study: Kickbacks and Bribes in Greater Miami
Wednesday, October 31
3:05 pm – 4:05 pm
Level 201

From approximately January 2006 through June 2012, Samuel Konell, 70, of Boca Raton, Florida, admitted to receive kickbacks and/or bribes in return for referring Medicare beneficiaries from the Miami-Dade state court system to Greater Miami Behavioral Healthcare Center Inc. to serve as patients. Konell knowling referred individuals who were not mentally ill or otherwise did not meet the criteria for PHP treatment. Konell admitted that his participation in the Greater Miami scheme resulted in the submission of claims to Medicare totaling between at least approximately $9.5 and $25 million. Eleven other individuals pleaded guilty and were sentenced for their roles in the scheme, including the owner of Greater Miami, three administrators and seven patient brokers.

This presentation will assist investigators in:

  • Approaching PHP investigations in a different manner, as opposed to traditional fraud schemes
  • Determining kickback/bribery schemes and attempts to disguise said payments
  • Recognizing techniques used in this investigation

Faculty

Julissa Monzon-Parsons
Special Agent, Office of Inspector General, U.S. Department of Health and Human Services

Ricardo Carcas, CFE
Special Agent, Office of Inspector General, U.S. Department of Health and Human Services

Expanding Your Investigative Skills

Medicaid Managed Care: Challenges and Opportunities for Investigating Medicaid Fraud
Tuesday, October 30
10:00 am – 11:00 am

Level 201

Developing a collaborative and consistent fraud-fighting approach between Medicaid Program Integrity (PI) units, Medicaid fraud control units (MFCUs), and Medicaid Managed Care Organization (MCO) SIUs is critical to successfully addressing health care fraud. Hear from SIU leaders in Medicaid Managed Care about the challenges they face state-to-state in their efforts to protect patients and safeguard Medicaid dollars. The speakers will discuss the impact of those challenges and highlight best practices from states that encourage collaboration and enable the successful conclusion of fraud investigations.

Faculty

Rick Munson, AHFI
Program Integrity Chief Compliance Officer & Vice President, Investigations, UnitedHealthcare

Nicholas Messuri, Esq
Vice President and Deputy General Counsel, Fraud Prevention & Recovery, DentaQuest

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

Kelly A. Bennett, JD, CFE, AHFI
Chief, Medicaid Program Integrity, Agency for Health Care Administration, State of Florida

Conducting Investigations
Tuesday, October 30
11:15 am – 12:15 pm
Level 101

This session will walk the audience through every step from the initiation of the investigation through the implementation of corrective actions. Key concepts will be discussed such as developing an investigative plan, leadership notification/escalation, management's role, reporting requirements, and criminal implications. Every facet of the investigative interview will be examined to include the location of the interview, the necessary interview participants, the role of labor in the interview process, documentation, and the different interview techniques utilized based on the type of interview being conducted.

This presentation will assist investigators in:

  • Developing an investigative plan and how to incorporate the plan throughout the investigation
  • Interviewing protocol and techniques and applying these techniques across different situations
  • Learning how to incorporate a variety of corrective actions to include making effective law enforcement referrals

Faculty

Tamara Neiman
Director, National Special Investigations Unit, Kaiser Permanente

Dan Falzon
Senior Manager, National Special Investigations Unit, Kaiser Permanente

Identifying Outliers and Confirming Suspicious Patterns to Support an Investigation
Tuesday, October 30
2:15 pm – 3:15 pm
Level 101

This session will review analytical approaches for investigating a provider that can be used after identifying that provider as an outlier to determine whether there is merit for further investigation. Attendees will be presented with some quick hits to run early in an investigation, such as conducting a review of the employer groups with exposure to identify suspect patterns, which can help to focus an investigation rather than lead to a fishing expedition. Faculty will walk attendees through the early stages of a de-identified case about a provider who was selected for review after appearing as an outlier amongst his peers in terms of the number of services billed. Faculty will walk through the steps the investigator took and the data analysis techniques used to determine if the outlier status was reasonably explained or if the provider warranted further investigation.

This presentation will assist investigators in:

  • Examining data for analyzing excessive hours billed
  • Identifying suspicious patterns such as large numbers of patients working for the same employer
  • Learning to look for spikes in utilization for the same or similar services for a particular set of patients to identify suspected FWA

Faculty

Rachel Wacht, CFE, HCAFA
Senior Fraud Investigator, Blue Cross and Blue Shield of Massachusetts

Innovative Approaches to Fraud Detection in Healthcare
Tuesday, October 30
3:30 pm - 4:30 pm
Level 201

With the never-ending stream of viable fraud leads, the importance of utilizing predictive modeling tools is never more important.  The faculty will discuss the need for predictive analytics, how it can streamline processes and help investigative units, and the variety of variables that vendors offer. Faculty will demonstrate how trends emerge with examples from controlled substance use (including compounded drugs and polypharmacy), cross-state activity, mixed-payment modalities, etc. from large PDMP (Prescription Drug Monitoring Program) dataset. Effectively managing the investigative process lends itself to an effective and efficiently executed investigation. For this portion of the panel presentation, attendees will learn how all of the pieces tie together for an end user to maximize their investigation.

This presentation will assist investigators in:

  • How predictive modeling tools can streamline processes and help investigate units
  • The importance of utilizing and leveraging multiple data sets to ensure accuracy
  • How to improve the efficiency of an investigation by using software solutions to manage the investigative workflow

Faculty:

Robert Case
Technical Fellow, MITRE Corporation 

Jaya Tripathi
Principal Scientist, MITRE Corporation

Carrie Ward, AHFI, CFE
Senior Vice President, Qlarant

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

The Challenges of Talents Development in Healthcare Special Investigation Units
Wednesday, October 31
10:45 am – 11:45 am
Level 301

American healthcare system has undergone various transformations that has rapidly increased the demand for talent development. The shift from volume-based to a value-based reimbursement. There have been a myriads of compliance policies over the past ten years that have created unanticipated dynamics on manpower resources and skillset requirement to keeping up with operational goals. One area of concern is the Special Investigation Units(SIU), this unit is a gatekeeper in safeguarding fraudulent practices and saddled with the responsibility of providing oversight functions on program integrity in healthcare organizations. Irrespective where the SIU resides in the organization, it's regarded as a statutory mandatory unit that provides checks and balances through various anti-fraud programs in our healthcare system. This presentation examines various structural defects in the contemporary SIU and its staffing models. The presenter will use both interviews methodology and observatory analyses to present some findings and recommendations with the aim of using this as a springboard to stimulate discussion on the evolving state of talent shortage and create conscious awareness on revolution in the traditional skillset necessary to tackle contemporary complex anti-fraud programs.

This presentation will assist investigators in:

  • Understanding of SIU structure and merit/demerit of different SIU staffing models
  • Discussing the emerging skillsets challenging the traditional SIU training and the evolution in SIU operation
  • Gaining knowledge of relevant talent acquisition and how to hire top notch staffers whose skillset are broad enough for the daunting task of fraud identification using spectrum of data and information to support the allegations

Faculty

Sunday Adesina, MSc, MPH, AHFI, CFE, CHDA,CPC-P, CPMA,CPCO
Sr. Healthcare Economics Consultant-Payment Integrity, UnitedHealth Group-Optum

Managing Conflict in the Health Care Fraud Ecosystem
Wednesday, October 31
1:55 pm – 2:55 pm
Level 201

The healthcare industry is consistently rife with conflict; conflict between providers and payers, members and payers, and within government and private programs. The concept of healthcare fraud, waste and abuse conjures up additional layers of conflict. Typical SIU managers and investigators face conflict within their own departments, with their Legal Departments, their Medical Management, and providers, members and law enforcement. This presentation will address how to mitigate these conflicts with soft skillsets and case study examples.

This presentation will assist investigators in:

  • Mitigating conflict between their SIU and company departments
  • Learning the best resources in dealing with joint investigations with law enforcement
  • Addressing obstacles in moving investigations forward - both within the payer and outside

Faculty

Alanna Lavelle MS.
Senior Principal, MITRECorporation

Haley Everson, MS.
Senior Investigator, Anthem BCBS

Are you getting the most out of your program integrity data?
Wednesday, October 31
3:05 pm – 4:05 pm
Level 101

Many program integrity organizations have access to large, rich data sources, and they are beginning to scratch the surface of using this data to catch more bad actors, evaluate interventions, and strengthen programs. CMS has started connecting program integrity claims, provider enrollment, and overpayments data, which has created opportunities to provide better insight into program and contractor performance and help investigators target bad actors. Some of the results, for instance in regards to how pay and chase works in practice, have been surprising. In this session, the presenter will discuss the benefits of connecting and improving program integrity data, key challenges and potential solutions, and ideas for opportunities.

This presentation will assist investigators in:

  • Identifying opportunities they may not have considered for using data to target bad actors
  • Recognizing how data can help them better evaluate their programs
  • Preparing to overcome major hurdles in improving their data

Faculty

Marin Gemmill-Toyama, PhD
Director, Division of Outcomes Measurement, U.S. Dept. of Health & Human Services, CMS

Building a Prepayment Team in the Medicaid Space
Wednesday, October 31
4:15 pm – 5:15 pm
Level 101

In early 2017, the Aetna Medicaid SIU team began the implementation of a team dedicated to Prepayment Investigations. Once the initial team was selected, they began the process of defining prepayment review for Aetna Medicaid, developing workflows, researching vendors and finally conducting a proof of concept with a vendor. Instead of presenting from a management perspective, Aetna’s Prepayment Investigators will describe the journey of embarking on this new adventure showing the viewpoint from the contributor level. The team will share the successes, pitfalls and many surprises discovered along the way. This will include building the relationships with the health plan leadership to implement this piece of the SIU process and the coordination needed between the state and health plans.

This presentation will assist investigators in:

  • Gaining insight on prepayment versus postpayment investigations
  • Learning successful strategies for starting a new project
  • Understanding how to navigate the different state regulations

Faculty

Arthur Hidalgo
Sr. Investigator, Aetna

Kimberly Poindexter, CPC
Senior Investigator, Aetna Medicaid

John Victoravich
Senior Investigator, Aetna Medicaid

Pharmacy and Opioid Schemes

Opioid Investigation: From the Tip to Prosecution
Tuesday, October 30
2:15 pm – 3:15 pm
Level 201

While the issues of pharmacy and opioid fraud have been widely discussed, it is also important to demonstrate ways to successfully prosecute the participants in those schemes to the fullest extent. Investigators working these cases put in countless hours, only to find that the information accumulated does not meet the necessary burden of proof to successfully move the case to the next level. This presentation will closely examine the opioid fraud trends in Florida and the United States Attorney's efforts to prosecute, in order to show the progression of the investigation starting with the suspicion of fraud through prosecution. The faculty will offer the prosecutor’s perspective to enable investigators to more successfully prepare their opioid cases. By closely reviewing a sample case, participants may better understand the critical elements of a prosecutable case regarding the continued fight against opioid Fraud.

This presentation will assist investigators in:

  • Recognizing what is important to make a case prosecutable
  • Gaining a better understanding of what case information is important to law
  • Illustrate the importance of working together to build the best case possible in preparation for court/trial

Faculty

Dawn Ezell
Investigative Consultant, UnitedHealthcare

Kelley Howard-Allen
Assistant United States Attorney, Middle District of Florida, Tampa Division

Prescription Drug Fraud Schemes
Tuesday, October 30
11:15 am – 12:15 pm
Level 201

Expert faculty will examine trends and schemes in the dynamic world of pharmaceuticals. Faculty will explore newly approved pharmaceuticals of concern, new schemes by criminals, legislative impacts, opioid plots, drug-treatment related ruses, and other areas of impact.

This presentation will assist investigators in:

  • Recognizing new pharmaceuticals and associated schemes on the rise in the community
  • Discussing the substance abuse treatment schemes and types of activity to be aware of

Faculty

Michael Cohen, DHSc, JD, PA-C
Operations Officer, Investigations Unit, Office of the Inspector General, U.S. Dept. of Health & Human Services

ERISA Kickback Arrangements in the Pharmaceutical Benefits Manager Space
Tuesday, October 30
10:00 am – 11:00 am
Level 201

This session will examine a case study on the conviction of the former CEO of a national Pharmacy Benefits Manager (PBM) and certain others. Faculty will explore the various investigative steps undertaken in unmasking a large complex kickback scheme impacting not only ERISA benefit plans but also Commercial and Medicare Advantage Plans. Key concepts to be examined in this presentation include: (1) the lack of transparency requiring a reliance upon cooperators; (2) the discovery of opportunities in pricing manipulations and kickback concealment; and (3) lessons learned in overcoming agency coordination challenges.

This presentation will assist investigators in:

  • Gaining a better understanding of potential vulnerabilities within the PBM space
  • Learning the areas of opportunities that can be used to manipulate drug pricing
  • Understanding the need of multi-agency coordination and the challenges faced in investigating

Faculty

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

Nathaniel Kummerfeld
AUSA, U.S. Attorney's Office, Eastern District of Texas

Developing Drug Diversion Cases through Data Analytics
Tuesday, October 30
3:30 pm – 4:30 pm
Level 201

With opioids being declared a public emergency, we are all looking for ways to combat this crisis, as well as collectively identify the drug diversion providers who fuel it. This session will offer insights on analytical tools proven successful in these type of investigations and provide participants with thoughts on useful fields to capture when requesting and running initial pharmacy claims data. The faculty will demonstrate how to use the data to create and utilize peer comparisons to identify providers of interest and identifying common mistakes when reviewing and performing analytics on controlled substance data. The faculty will also discuss some investigative steps and shared experiences so that an experienced investigator can replicate this process in their own SIU.

This presentation will assist investigators in:

  • Recognizing data fields required to successfully run and analyze pharmacy data
  • Examining how peer comparisons can be created and how they are useful in identifying providers of interest, as well as supportive in prosecutions
  • Determining some common diversion billing schemes to be aware of when reviewing claims data

Faculty

Janet Bonham, AHFI
Senior Investigator, Anthem

Aspen Taylor, CPC
Investigator II, Anthem

Evolving Role of Data Analytics in Opioid Fraud and Abuse Investigations
Wednesday, October 31
10:45 am – 11:45 am
Level 201

Faculty from the Department of Justics Criminal Division, Health Care Fraud Unit will discuss trends and investigative/data analytic strategies to develop and successfully prosecute cases stemming from the opioid epidemic. The faculty will discuss data analytic methodology that has helped increase both outcomes in the health care fraud and the opioid fraud and abuse programs. The presentation will cover not only prescriber and pharmacy targets, but it will also review additional health care providers involved in opioid-related schemes, included but not limited to drug testing laboratories and sober homes.

This presentation will assist investigators in:

  • Recognizing the importance forming investigative/prosecutorial team to stop opioid abuse. 
  • Learning approaches to investigate and harness data to develop cases.
  • Identifying best practices and techniques already found to be successful in the field.

Faculty

Naomi Adaniya PhD
Policy Analyst, U.S. Department of Justice, Criminal Division, Fraud Section, Health Care Fraud Unit

Kimberly Coffey
Program Analyst, U.S. Department of Justice, Criminal Division, Fraud Section, Health Care Fraud Unit

Telemedicine and Telemarketing: The evolution of pharmaceutical schemes
Wednesday, October 31
1:55 pm – 2:55 pm
Level 201

This presentation will highlight several transdermal creams and ointments that are the subject of abusive pharmaceutical billing practices. Specifically, investigators have identified several National Drug Codes (NDC) for creams/ointments that over the past 2 to 4 years have been billed to Medicare and other government and private health plans for billions of dollars. These fraudulent providers are using telemarketing, telemedicine and patient leads to submit false claims. The presenter will highlight the NDCs and give a general overview of active criminal investigations involving these schemes. Additionally, attendees will be given a template for how to identify the abusive providers and a guide to conducting investigations.

This presentation will assist investigators in:

  • Identifying vulnerable NDCs and how to build an investigation
  • • Recognizing the current financial impact of the schemes to government and private health plans

Faculty

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

Pharmacy Fraud and the Use of CMS' Part D Eligibility System to Data Mine Patients
Wednesday, October 31
3:05 pm – 4:05 pm
Level 101

Investigations have revealed that pharmacies that have access to CMS' E-1 Transaction Facilitator system have identified methods of using that system to data mine patients to target sales and marketing schemes to maximize the potential of reimbursement through fraudulent sales and marketing. Specifically, pharmacies obtain Medicare beneficiary information through bogus web landing pages, television commercials and print media where potential patients provide the demographic information needed to query the E-1 system. There is little currently known about the potential vulnerabilities of this issue. The presentation will provide an overview of the E-1 system, how it works, who should be using it, under what circumstances it should be queried, and how the fraud schemes work to utilize this system for nefarious purposes.

This presentation will assist investigators in:

  • Explaining the E-1 transaction facilitator system
  • Recognizing how to obtain data to open investigations in this area
  • Creating a roadmap for future investigations based on a case example

Faculty

Eric Rubenstein
Special Agent, Office of Inspector General, U.S. Department of Health and Human Services

1 + 1 + N = Unparalleled Results – HFPP Changing the Game in Identifying Fraud, Waste, and Abuse
Wednesday, October 31
4:15 pm – 5:15 pm
Level 201

The HFPP is a voluntary, public-private partnership between the federal government, state agencies, law enforcement, private health insurance plans, employer organizations, and health care anti-fraud associations to identify and reduce fraud, waste, and abuse across the healthcare sector. The faculty in this session will illustrate the unique claims data set collected by the HFPP providing heightened insights into fraud, waste, and abuse. The faculty will place a focus on recent studies in behavioral health and substance abuse, such as urine drug testing and outpatient psychotherapy. The faculty will also discuss the use of the data sources in areas such as geographic dispersion of rendering and referring providers; spike analysis and unusual patterns of claims submissions; and time bandit analysis.

This presentation will assist investigators in:

  • Understanding the Healthcare Fraud Prevention Partnership and the value of the unique data set from which the HFPP conducts studies
  • Recognizing the value of the exclusive findings from recent studies in the areas of behavioral health, urine drug testing and advanced analytics
  • Summarizing how Partners can incorporate study findings into their investigations and coordinate with law enforcement and other payers to build a stronger case

Faculty

Tim Carrico
HFPP Studies Manager, Trusted Third Party

Dan Kreitman
HFPP Program Manager, Trusted Third Party

Case Studies to Address Trending Schemes in Health Care Fraud

Public and Private Partners Successfully Investigate Introperative Monitoring and Pain Management Scheme
Tuesday, October 30
11:15 am – 12:15 pm
Level 101

Hear about the successful efforts of the public and private sectors to investigate an IOM and pain management scheme which led to criminal conviction, over 1.1 million dollars in restitution, over 2.5 million dollars in savings and an agreement to reimburse the federal government 20 million dollars to Medicare and Tricare. Faculty who worked the case will offer insight on the techniques employed in the investigation including data-mining, witness interviews, review of business records, review of medical records/policies, cellular telephone records, interviews with Subject Matter Experts (SMEs), issuance of FGJ subpoenas, exhaustive review of claims data and datamining, and both civil/criminal court preparation and filings. Faculty will also explain how data mining was invaluable in eventually leading to identification of specific codes at issue, the overall exposure and the identification of additional locations involved in the scheme.

This presentation will assist investigators in:

  • Examining data-mining techniques that can be used in complex investigations.
  • Enhancing their investigative skills
  • Mining data for specific codes and issues

Faculty

John Houston, CPC
Director, SIU, Anthem, Inc.

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

MCO Data Offers the Critical Evidence in the Thauberger et al. Chiropractic Case
Tuesday, October 30
2:15 pm – 3:15 pm
Level 201

Learn about a complex investigation that includes undercover agents, interviews, data analytics, and survelliance to investigate a chiropractor in the Western District of Kentucky who was committing health care fraud against Medicaid, MCOs, Medicare and commercial health and auto insurance companies. Law enforcement from FBI, HHS-OIG and Kentucky MFCU jointly conducted the investigation. The faculty will provide their perspective into the extensive investigation and the data analytics critical to the breakthrough in the case. Participants will also gain insights on how important the MCO referral of provider anomalies and data analytic patterns can be to a LE investigations. In addition, participants will gain a better understanding of how collaboration and coordination can be replicated along with the use of data analytics to establish fraudulent patterns of billing.

This presentation will assist investigators in:

  • Examining the importance of MCO referral of provider anomalies and data analytic patterns can be to a LE investigations
  • Discussing the value of communication and collaboration amongst agencies in obtaining a successful investigation and prosecution
  • Understanding the importance of the interview in conducting these investigations, as well as how to overcome some of the hurdles when corroborating Medicaid patients' statements when they have other issues which could affect their credibility

Faculty

Janet Bonham, AHFI
Senior Investigator, Anthem

Lettricea Jefferson-Webb, JD
Assistant United States Attorney (AUSA), United States Attorney's Office, Western District of Kentucky

Operation "Carman" - Advanced Investigative Techniques and Use of Informants
Wednesday, October 31
10:45 am – 11:45 am
Level 301

The presentation focuses on several DME sales representatives and a California based DME supplier. Agents from the FBI, OIG and MFCU units in three states worked in collaboration to successfully investigate this case. The investigation involved multiple search warrants, dozens of subpoenas for records, analysis of claims data over a six year time period involving multiple DME suppliers and referring providers. Faculty will illustrate the case which involved kickback payments, false records and representations and "free" equipment as inducements for patients to accept power wheelchairs and back braces they didn't want, need or qualify for. Key concepts offered during the presentation will focus on the use of an informant and important techniques for interviewing elderly patients. Presenters will discuss organization and review of records and how that played a key role in the eventual prosecution in this case.

This presentation will assist investigators in:

  • Learning the effective use of undercover surveillance and use of informants in HCF investigations
  • Gaining knowledge and insight of the importance of interview skills and techniques for elderly patients
  • Understanding the importance of summary testimony, including financial summaries at trial

Faculty

Richard Haines
Special Agent, U.S. Department of Health and Human Services, Office of Inspector General

Clayton Goldsmith
Special Agent, U.S. Department of Justice, Federal Bureau of Investigations

Stuart Canale, Co-presenter
Assistant U.S. Attorney, U.S. Attorney's Office - Memphis, Tennessee

Matthew Wilson
Assistant U.S. Attorney, U.S. Attorney’s Office

Ophthalmology Schemes: Examining the Melgen Case Study
Wednesday, October 31
1:55 pm – 2:55 pm
Level 201

In late 2011, FBI Miami initiated an investigation on Dr. Salomon Melgen, an Ophthalmologist specializing in retina diseases, who was the top billing Medicare provider for multiple years in Florida. Dr. Melgen fraudulently diagnosed patients with the disease Wet Age Related Macular Degeneration to fraudulently bill Medicare for medically unnecessary diagnostic tests and procedures. Dr. Melgen billed Medicare more than $190 million between 2008 and 2013. The FBI, Department of Health and Human Services (HHS)/Office of the Inspector General, Defense Criminal Investigative Services, Railroad Retirement Plan, and private insurance companies all contributed to the investigation. Participants will hear about how this case was the first intelligence based HCF investigation in FBI Miami, it is an excellent example of how analytical techniques along with investigative methods can be used to evaluate healthcare information and data to develop an intelligence based investigation.

This presentation will assist investigators in:

  • Examining the importance of proactively analyzing data to identify top procedure codes and top billers in the country;
  • Determining the use of data analytics to assist medical experts review of patient records; and
  • Illustrative the effectiveness of peer comparisons to demonstrate outliers in medical billings

Faculty

Frances Szczepanski
Special Agent, U.S. Department of Justice, Federal Bureau of Investigations

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

Home Health Fraud: Making Related Drug Trafficking, Money Laundering and Immigration Fraud Possible
Wednesday, October 31
3:05 pm – 4:05 pm
Level 101

This case study will illustrate how a health care fraud scheme, involving fraudulent home health RAP claims, made possible a number of other interrelated schemes such as the laundering of millions of dollars in ill-gotten gains to cash, and the trafficking of illicit marijuana from Colorado to Florida for illegal distribution. This case also highlights a relatively new immigration fraud scheme regarding the falsification of US Customs Form N-648, Medical Certification for Disability Exceptions, unjustly allowing immigrants a "fast-track" to government benefit programs. Participants will learn how through the rapid and continuous submission of home health "RAP" claims, these entities were able to quickly and efficiently receive millions in payment based on false claims, sometimes over a million dollars in a single month. The presentation will also highlight the use of Medicare billing data tied with financial data to prove the fraud during all stages of the investigation.

This presentation will assist investigators in:

  • Converting large data sets into understandable formats for juries to comprehend
  • Using billing data with financial data to prove the fraud
  • Navigating large scale, interrelated crime schemes involving multiple investigative agencies

Faculty

Isaac Bledsoe
Special Agent, Office of Inspector General, U.S. Department of Health and Human Services

Tim Gorman
Special Agent, U.S. Department of Justice, Federal Bureau of Investigations – Tampa

Shrink Rap: Key Lessons from a Home Health Case
Wednesday, October 31
4:15 pm – 5:15 pm
Level 201

The Shrink Rap investigation primarily targeted two home health aide agencies in New Jersey that employed dozens of accomplices and several nominee bank accounts to conduct a multi-year, multi-million dollar Medicaid fraud and money laundering scam. Faculty will showcase various investigative techniques including the use of confidential informants, undercover operatives, surveillance (both physical and electronic), along with the use of dozens of search and seizure warrants and the intensive review of voluminous documentary evidence. Faculty will convey important lessons learned from this investigation including the value of following the money and identifying and utilizing all available external investigative resources. Faculty will also discuss the human source recruitment campaign used in the case to identify and enlist embedded employees within the targeted entity as well as introduce new informants capable of infiltrating the criminal scheme.

This presentation will assist investigators in:

  • Determining the value of following the money
  • Examining strategies for creating a human source recruitment campaign to identify and enlist embedded employees within the targeted entity as well as introduce new informants capable of infiltrating the criminal scheme
  • Identifying and utilizing all available external investigative resources

Faculty

Joshua M. Liberman
Special Agent, U.S. Department of Justice, Federal Bureau of Investigations

Julie A. Gettings
Special Agent, U.S. Department of Justice, Federal Bureau of Investigations

Emerging Trends in Health Care Fraud

Emerging Issues in Medicare Fraud
Tuesday, October 30
10:00 am – 11:00 am
Level 201

Participate in this annual 'Health Care Fraud Trends' presentation with one of the leading experts from the Office of the Inspector General, U.S. Department of Health and Human Services on common fraud schemes and emerging trends affecting Medicare and Medicaid. Participants will hear about special iniatives to fight health care fraud in the government programs. In addition, the participants will learn how data analytics is being leveraged to find red flags.

This presentation will assist investigators in:

  • Recognizing emerging fraud schemes and trends in Medicaid and Medicare programs. 
  • Determining how schemes in public programs might also impact commercial insurers.

Faculty

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

Dark Web: Beyond the Silkroad
Tuesday, October 30
10:00 am – 11:00 am
Level 201

The Dark Web first gained recognition in 2010 with the creation of Silk Road (Dark Web Marketplace). Over the last 5 years, over 80 marketplaces have picked up were Silk Road left off. It is estimated that between 24 and 100 billion dollars are spent each year on the illicit purchase of pharmaceuticals and other drugs purchased on the Dark Web. From an operational prospective, this is a platform to investigate multiple targets, unlike cases that may only target one individual or a group of connected individuals. Partnerships with United States Postal Inspectors, DEA and other law enforcement agencies have provided the ground work to successfully identify and eventually prosecute Dark Web vendors. Faculty will highlight how analysis of reporting, confidential sources and undercover operations have been the cornerstone of the case work to date.

This presentation will assist investigators in:

  • Gaining a ground level understanding of how the Dark Web is being utilized to facilitate a growing number of drug transactions, to include pharmaceuticals.
  • Understanding how cases can be initiated and ultimately prosecuted at a federal level.
  • Recognizing how the rise of Dark Web Drug Marketplaces will affect a new segment of the population and have global impact on our health care system.

Faculty

Rhetten S. Close
Special Agent, U.S. Department of Justice, Federal Bureau of Investigations

Brandon E. Burke
Special Agent, U.S. Department of Justice, Federal Bureau of Investigations

Karl Kadon
Assistant U.S. Attorney, U.S. Attorney’s Office - Southern District of Ohio

Medical ID Theft: Investigative tools used by law enforcement
Tuesday, October 30
11:15 am – 12:15 pm
Level 201

Medical ID Theft is a growing scheme that will not only affect public programs like Medicare but also private insurers. This presentation will show how this particular scheme affected both public and private payers, the victimized providers and used tools that are openly available to perpetrate the scheme. The identification of these tools will help future investigators identify potential ID thefts. This presentation will cover a Medicare fraud investigation in Palm Beach, Florida that involved the subject stealing the identity of older providers and then submitting back dated claims for deceased beneficiaries for services not rendered. Faculty will discuss the investigative tools used by law enformcent to uncover schemes and the need to educate potential partners can help to identify fraud.

This presentation will assist investigators in:

  • Identifying potential fraudulent claims in both public and private healthcare programs 
  • Determining potential provider and beneficiary identity theft
  • Recognizing the need to educate partners in private entities and local law enforcement in identifying potential healthcare fraud.

Faculty

Radu Pisano CFE
Special Agent, U.S. Department of Health and Human Services - Office of Inspector General

Ellen Cohen, JD
Assistant United States Attorney, U.S. Department of Justice - Southern District of Florida (SDFL)

Top Legal Issues in Health Care Fraud
Tuesday, October 30
2:15 pm – 3:15 pm
Level 201

A practicing attorney working on health care fraud cases 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.

This presentation will assist investigators in:

  • Determining how regulatory and legislative changes will impact their investigations
  • Examining state and federal decisions and the repercussions for fraud schemes and cases

Faculty

William F. Gould
Partner, Holland & Knight LLP

Fraud + Cyber = Next Level Investigation Capabilities
Wednesday, October 31
10:45 am – 11:45 am
Level 201

In tackling the broad landscape of health care fraud, investigators have gained a wide variety of investigative techniques and tools in the toolkit. Faculty will demonstrate how participants can partner with internal IT experts and use cyber investigation techniques and data sets to supplement classical health care fraud investigations. The faculty will share strategies of how adding IT data sets enriched evidence and strengthened cases turned over to Law Enforcement.

This presentation will assist investigators in:

  • Using cyber data of many types to enhance healthcare investigations
  • Requesting, interpreting and presenting cyber data internally and externally
  • Determining how build critical partnerships internally/externally in this effort

Faculty

Quinn Shamblin, C|CISO, CISM, MBA, ITIL, GCFA
EIS Director, Global Fraud Protection, Optum

Joseph Popillo, AHFI, CPCO, CPC-A
Associate Director, Program Integrity OptumCare

Social Media & OSINT Exploitation: A Tactical Analyst's Approach to Fraud Investigations
Wednesday, October 31
1:55 pm – 2:55 pm
Level 201

The need for Social Media and OSINT exploration often stems from leads created from data analysis in an investigation. The specific intelligence gleaned from the exploitation of OSINT is used in an investigation to identify information not immediately obvious in strategic or statistical data, such as information presented in a YouTube video or allegations contained in an online review. Additionally, analysis of Social Media profiles could clarify a suspected connection between individuals and/or provide personal insights that may otherwise be unknown. This information when combined with data analysis and investigator research lead to an enhanced picture of the alleged fraud. This session will provide an overview of how the tactical analysis team from one insurer approaches a fraud investigation, tips, tricks and best practices will be included throughout. Methods and techniques in this presentation can be immediately implemented in investigations.

This presentation will assist investigators in:

  • Examining how to effectively mine Social Media and OSINT for data and connections
  • Determining tactical approaches to address commonly encountered issues within an investigation
  • Incorporating visualizations such as link analysis or maps to assist in building the most comprehensive picture of a case investigation

Faculty

Donna Jallits
Informatics Senior Specialist, Cigna

Shawn Lipsey
Informatics Senior Specialist, Cigna

E-medicine: How the Rise of Click Bait Has Upped the Game in Tele-Health Fraud
Wednesday, October 31
3:05 pm - 4:05 pm
Level 201

An in-depth look at how fraudsters use click-bait and other marketing schemes to con their way into millions in prescriptions with doctors rarely ever speaking to a single patient. This presentation will focus on the emerging trend of using Tele and E-medicine physicians as a way to disguise fraudulent and medically unnecessary products and services. The presentation will include two active case examples, a multi-state topical cream pharmacy scheme and an international DME scheme, which resulted in millions in paid claims.

This presentation will assist investigators in:

  • Examining how fraudulent providers use advances in technology and business, such as social media, tele-marketing call centers, VoIP phone services, tele-medicine, and virtual offices, to hide and steal millions from public and private healthcare benefit programs.
  • Discovering emerging trends of tele-medicine mail order fraud schemes.
  • Identifying investigative techniques that uncover fraudulent providers through data and other means.

Faculty

Bob Turner
Special Agent – Nashville Field Office, U.S. Department of Health and Human Services, Office of Inspector General

Shawn McAleer
Special Agent – Atlanta Regional Office, U.S. Department of Health and Human Services, Office of Inspector General

Gregory Peacock
Special Agent, U.S. Department of Justice, Federal Bureau of Investigation – Atlanta Field Office

Detecting and Preventing Fraud, Waste and Abuse in Telehealth: A CMS Perspective
October 31
4:15 pm – 5:15 pm
Level 201

The future is here and with an ever-increasing goal to provide quality care with the least amount of burden for not only the beneficiaries, but also those doctors that provide these services. But with this comes the potential for increased fraudulent activity. The faculty will describe telehealth and telemedicine services from a CMS perspective, including the potential vulnerabilities, what to look for and ways to investigate. During the presentation, the faculty will discuss issues that have been encountered in DME, Home Health and Hospice. They will provide case examples, data analytic strategies, codes used and investigation methodologies, and other proactive approaches. Attendees will take away awareness of the trends associated with Telemedicine, red flag codes, investigative strategies and proactive ideas.

This presentation will assist investigators in:

  • Increasing their awareness of the trends associated with Telemedicine, red flag codes, investigative strategies and proactive ideas.
  • Recognizing potential fraud in DME, Home Health and Hospice.
  • Determining where there are vulnerabilities, existing schemes, and ways to investigate telehealth schemes

Faculty

Lawrence Ball
Director, Division of Field Operations West, Center for Program Integrity, Centers for Medicare and Medicaid Services (CMS)

Brent Person
Senior Investigator and Technical Advisor, Center for Program Integrity, Centers for Medicare and Medicaid Services (CMS)

Carynne Godfrey
Part B Provider Outreach & Education Representative, Noridian Healthcare Solutions, LLC

Dental Fraud Schemes

Tooth or Consequences: Dentists and Cross Plan Billings
Tuesday, October 30
10:00 am – 11:00 am
Level 301

General dentists are increasingly choosing to incorporate services reimbursed by medical plans into their practices. In fact, many have made a conscious decision to limit their practices to services used to treat specific conditions that are only reimbursed by the medical plan. There is an increasing need for health plans whose products span both medical and dental specialty to develop mechanisms to simultaneously examine potential fraud across claim forms/platforms. In the absence of reviewing the data concurrently, valuable insight may be lost and the potential for fraud determination diminished. The information provided in this session will also assist insurers who process only medical claims to identify potential FWA by dentists.

This presentation will assist investigators in:

  • Understanding the issues involved with cross claim billing by dentists and the unique challenges that may influence how an investigation might be approached
  • Learning a process/strategy by which claims data may be evaluated to maximize identification of FWA and potential recoveries
  • Recognizing associated CPT/CDT codes for data mining to identify potential FWA through illustrations of typical billing patterns

Faculty

Mary Morales, MHSA, RDH, AHF
Sr. Clinical Investigator, Anthem, Inc

Amy Krakower, Esq.
Manager, Advisory Services, Optum

An Analytic Approach to Dental FWA
Tuesday, October 30
11:15 am – 12:15 pm
Level 201

This session will demonstrate how analytics are used for detecting dental fraud, plan design vulnerabilities, patterns exhibited in dental fraud, and for making recommendations to prevent FWA. Statistical comparisons using analytics will demonstrate aberrant/egregious behavior in dental specialty plans and Dentists' claim submissions. The faculty will utilize case studies, slides and discussions to demonstrate dental FWA activities, how analytics is used to identify the codes most commonly abused, and how a plan design, especially with rich benefits, can drive FWA. The session will also include a discussion of an innovative letter campaign used to change abusive billing behaviors identified through analytics.

This presentation will assist investigators in:

  • Recognizing how data analytics can compare dentists to their peers and dental benefit plans to other dental benefit plans. The discussion reviewed an analytics FWA system and how it profiles Dentists and plans to identify FWA
  • Leveraging data analytics and assist in plan design
  • Drafting a proactive letter campaign driven by analytics that can change aberrant behavior and create savings

Faculty

Debra Sahulka, RDH, MBA
Clinical Fraud Investigator, Anthem Inc.

Stewart R Balikov, DDS
State Dental Director, UM Department, Anthem Inc.

The Case of Dental Fraud from A to Dr. Z
Tuesday, October 30
2:15 pm – 3:15 pm
Level 201

This is a case study of a Virginia Dentist who plead guilty to healthcare fraud in December 2017. The faculty will discuss the three main parts of this case which involve Medicaid and private insurers. The first scheme involves billing for services not rendered, and the second includes using inappropriate CDT codes that resulted in higher reimbursements. Finally, the third scheme involves submitting incorrect dates of service for procedures actually performed after the termination of the patients' insurance coverage. The presentation will explain the processes of discovery of outlier behavior, the review of the records, presenting the findings to the provider and/or law agencies, the recovery of payments, and the referral and subsequent federal healthcare fraud case.

This presentation will assist investigators in:

  • Identifying multiple dental fraud schemes
  • Determining outlier providers
  • Recognizing the process for analyzing patient records.

Faculty

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

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

Medicaid Dental Fraud Investigative Case Study
Tuesday, October 30
3:30 pm – 4:30 pm
Level 201

Faculty in this session will walk attendees through an investigative case study of how inappropriate patterns of billing concerning a Periodontist were discovered. In addition, the faculty will demonstrate how a Periodontal Codes Peer Comparison revealed impossible days for the practice. The faculty will discuss specific codes and then review the red flags to find additional fraudulent billing schemes. Attendees will gain significant insight on how valuable it is to review analytics in order to identify outliers as well as impossible days. Additionally, attendees will obtain knowledge about how to identify inappropriate patterns of billing concerning the above outlined dental schemes.

This presentation will assist investigators in:

  • Recognizing the steps of an investigation based on lessons learned from a real case study
  • Identifying multiple fraudulent dental schemes that occurred under a NJ Medicaid Managed Care Organization
  • Gaining knowledge about dental procedures and how to utilize analytics in order to identify impossible days

Faculty

Megan Brennan, CPC, CPMA
Supervisor, Horizon NJ Health

Jennifer Barton, CFE
Senior Investigator, Horizon NJ Health

General Anesthesia in Dentistry - How to determine units of time
Wednesday, October 31
10:45 am – 11:45 am
Level 101

General Anesthesia (GA) for Dental Procedures in the dental/Oral Surgical Office is a medically induced coma with loss of protective reflexes resulting from the administration of one or more general anesthetic agents. A variety of medications may be administered with the overall aim of ensuring sleep, amnesia, analgesia, relaxation of skeletal muscles, and loss of control of reflexes of the autonomic nervous system dependent upon the depth of anesthesia administered. It is important to note that the ADA (American Dental Association) created codes to identify levels (planes) of anesthesia. However, according to the code descriptors within the ADA Current Dental Terminology (CDT) "The level of anesthesia is determined by the anesthesia provider's documentation of the anesthetic agents effects upon the central nervous system and not dependent upon the route of administration."

This presentation will assist investigators in:

  • Determining start and stop times of anesthetic services
  • Understanding a quality anesthetic record from one that is poor
  • Developing a better understanding of the types of drugs used and their pharmacology

Faculty

George Koumaras, DDS
Oral and Maxillofacial Surgeon, National Dental Director, Anthem Inc.

Richard M. Celko, DMD, MBA
Dental Director, UPMC Health Plan

Dental Fraud: A Law Enforcement Case Study
Wednesday, October 31
1:55 pm – 2:55 pm
Level 201

The faculty in this session will review a recent healthcare fraud investigation involving a dentist in Southern California. The case briefing will demonstrate the steps followed to successfully bring the investigation to the DOJ Strike Force in the Central District of California. The briefing will follow a timeline of events from the issuance of the NHCAA alert/Request for Investigative Assistance through to the judicial aspects of the case. The presenter will also explain how dental fraud cases are developed, how law enforcement receives and uses information from the SIU’s, and the importance of the SIU’s and law enforcement working together to conduct dental fraud investigations. The faculty will discuss patient and employee interviews, interviews with dentists, specific dental fraud schemes and red flags, as well as how the witnesses for the case were determined.

This presentation will assist investigators in:

  • Utilizing different approaches and techniques for investigating dental fraud.
  • Presenting real examples on how to advance your dental case through the investigative stage of the case, from claims analysis to interviews.
  • Discussing some of the pitfalls experienced with investigating dental fraud, along with the successes.

Faculty

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

Dorene Whaley
Senior Investigator, MetLife

A Bulldog in a Skirt – A novel dental fraud scheme by a charismatic lady
Wednesday, October 31
3:05 pm – 4:05 pm
Level 201

This session will examine a dental fraud scheme designed to steal the identities of various individuals, including dentists, and use their identities without their knowledge to open merchant accounts with consumer dental financing programs. To gain access to the public programs, false and misleading enrollment applications were submitted. Once the fraudulent merchant accounts were opened, patients were billed for charges that were inflated, never authorized, or never approved and the subject was paid over $1 million. This scheme also impacted a private health insurer, whereby false and inflated insurance claims were submitted for dental services that were never rendered. Participants will learn lessons for overcoming the challenges of this and similar schemes.

This presentation will assist investigators in:

  • Understanding the sophisticated misuse of CareCredit in this fraud scheme
  • Summarizing the lessons learned and recognizing how to encourage others to pursue sophisticated fraudsters despite the associated frustrations

Faculty

Jessica Marrone
Special Agent, U.S. Department of Justice, Federal Bureau of Investigations

Shannon Cornelius, HCAFA, DIA
Investigative Lead / Special Investigations Unit, Humana

Dental Fraud and an Investigative Plan
Wednesday, October 31
4:15 pm – 5:15 pm
Level 201

Faculty will offer insights from a dental case being prosecuted out of the Southern District of New York. Participants will hear about how information was obtained from various state and local resources, and how agents analyzed data and patterns to identify red flags. Some of the key investigation skills that will be highlighted are establishing and managing informants, conducting undercover operations, and conducting interviews. The faculty will demonstrate how cell phone evidence-seizure and benefits of electronic evidence can be used in cases.

This presentation will assist investigators in:

  • Becoming proficient with developing sources and undercover/consensual monitorings
  • Identifying red flags and developing an investigative plan with dental fraud cases

Faculty

Steven Kay
Special Agent, U.S. Department of Health and Human Services, Office of Inspector General

SEMINARS
THURSDAY, NOVEMBER 1
8:30 am – 10:30 am

Making the Seamless Referral to Law Enforcement
Level 201

Want to make sure your referrals to law enforcement are better? The attentive and thorough referral from an MCO can be the difference in a successful prosecution and a provider that continues to slide under the radar committing fraud. It is essential the MCOs work with their respective law enforcement partners to "take down" the bad actors. Communication with law enforcement is essential, as well as, having a basic understanding of the laws potentially being violated. Faculty will highlight the valuable information that MCOs can offer to law enforcement partners and outline the expectations and needs of law enforcement to help with making a more seamless referral that works in favor of law enforcement and the MCO.

This presentation will assist investigators in:

  • Recognizing the expectations and needs of law enforcement
  • Demonstrating the value of the information the MCO has to offer
  • Developing a referral that benefits law enforcement and the MCO

Faculty

Kelly Hensley AHFI, CPC-A
Senior Investigator, Anthem

Chris Dunkle
Special Agent, Office of Investigations, U.S. Department of Health and Human Services

Kate Smith
Assistant U.S. Attorney, U.S. Attorney's Office, Eastern District of New York

Health Care Fraud Investigation Ethics Seminar

Each year, NHCAA hosts this 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 seminar is designed to meet the American Certified Fraud Examiner CFE ethics training requirement.

This presentation will assist investigators in:

  • Explaining an investigator’s ethical responsibilities, specifically during the phases of an investigation
  • Articulating the importance of creating and supporting an ethical culture in organizations
  • Defining the ethical investigation principles

Faculty

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

Ralph Carpenter
Retired Senior Director, SIU, Aetna, Inc.

Sara A. Walker, Esq.
Associate General Counsel, Blue Cross Blue Shield of Massachusetts

The Use of Data Analysis in Health Care Fraud Investigation and Prosecution
Level 301

This seminar will discuss how data was used in the investigation and prosecution of Dr. Syed Imran Ahmed. A group of agents, data analysists and prosecutors will explain how Dr. Ahmed was successfully prosecuted in the Eastern District of New York for a multi-million dollar health care fraud scheme in which he billed Medicare for incision and drainage and wound debridement procedures that he did not perform. This session will also explain how data analytics detected particular patterns in Dr. Ahmed's billings and was used in valuable ways through the prosecution and trial. Participants will gain insights on how data should be organized and prepared for trial in a clear and effective manner. The faculty will provide their thoughts on how the investigative strategy utilized in this case could be replicated in other investigations, including suggestions and tips for how analysts, investigators, and attorneys can collaborate in effective ways.

This presentation will assist investigators in:

  • Leveraging data analysis in the investigation and prosecution of health care fraud
  • Organizing data for presentation at trial in a clear and effective manner for the jury
  • Collaborating effectively among data analysts, investigators, and attorneys


Faculty

Brendan Stewart
Prosecutor, Assistant Chief, U.S. Department of Justice

Debra Jaroslawicz
Prosecutor, Trial Attorney, U.S. Department of Justice

Sue O'Connor
Investigator, Office of Inspector General, Office of Investigations, U.S. Department of Health and Human Services

David Lee
Special Agent, U.S. Department of Justice, Federal Bureau of Investigation

Wendy Gazzano
Senior Program Integrity Analyst, SafeGuard Services LLC

Joseph Giambalvo
Former Special Agent, Office of Inspector General, Office of Investigations, U.S. Department of Health and Human Services

Dental Fraud and Abuse: The Evolution of Current Common Schemes
Level 201

Dental fraud, waste and abuse schemes tend to present themselves in somewhat habitual forms, however over the past few years, some new schemes have emerged. The progression of technology and yearly updates to the CDT code set may create more opportunities for future fraud waste and abuse schemes. A review of the present schemes is helpful to keep in mind as investigators begin to consider emerging and possible future schemes along with examples of dental abuse as seen by both Commercial and Public investigators. This session will provide a ‘level set’ type review of the most current schemes, allowing investigators to build into discovering emerging and possible upcoming schemes and/or coding irregularities across a wide variety of clinical areas within Diagnostic, Restorative, Periodontal, Oral Surgery and other areas. Non-clinical anomalies within claim submissions, supporting treatment and diagnostic documentation, and narratives will also be part of the survey.

This presentation will assist investigators in:

  • Understanding the differences between Fraud and Abuse in the dental arena
  • Recognizing the similarities and differences between Commercial and Public sector dental plans relative to dental fraud and abuse
  • Identifying the opportunities for fraud and abuse where duel eligibility exists between medical and dental plans in both Commercial and Non-Commercial dental plans

Faculty

Stewart Balikov, DDS, AHFI
State Dental Director, Utilization Management, Anthem, Inc

Jason Coomer, DMD
SIU Dental Investigator, Humana, Inc.

Essential Management Skills for Anti-Fraud Leaders
Level 201

In this seminar, faculty will address some critical management issues for middle managers. Knowing how to move cases and projects through the department and across an organization can be difficult. This seminar will offer participants with insight on productivity and project management. Participants will learn how to manage the dynamics of moving projects from start to finish and navigating the work place effectively and efficiently. The human element of managing projects and conflict will also be addressed. Faculty will touch on how to understand office politics, and recognize and navigate generational differences.

This presentation will assist investigators in:

  • Addressing challenges on teams and with coworkers in effective and productive ways
  • Advancing projects across a team and through the organization
  • Recognizing areas of self-development and identifying strategies for success

Faculty

Jennifer Trussell
Chief Investigator, U.S. Department of Health and Human Service, Office of Inspector General

Rick Munson
Program Integrity Chief Compliance Officer & Vice President, Investigations, Unitedhealthcare Investigations

Shimon Richmond
Special Agent in Charge, U.S. Department of Health and Human Services, Office of Inspector General

Anti-Fraud Solutions

Government Policy Limitations and Their Impact on Medical Review
Tuesday, October 30
10:00 am – 11:00 am
Presented by Cotiviti (formerly Verscend), A NHCAA Platinum Supporting Member 

In January, the U.S. Department of Justice issued a memorandum limiting the use of agency guidance documents in affirmative civil enforcement cases. The change includes guidance issued by the U.S. Department of Health and Human Services, Office of Inspector General as well as the Centers for Medicare & Medicaid Services’ (CMS), Local Coverage Determinations (LCDs) and Medicare billing manuals. This session explores these changes, helping participants navigate appropriate and enforceable review resources to use and the benefits and pitfalls of creating plan-developed medical policies.

This presentation will assist investigators in:

  • Recognizing the significance of a newly released U.S. Department of Justice memorandum on medical record reviews
  • Determining how to better leverage coding definitions and guidance
  • Describing benefits and pitfalls of creating internal policies to mitigate these issues

Faculty

Mark Starinsky
Manager of FWA, Cotiviti (formerly Verscend)

Gerry Petrowski, CPC
Supervisor, Medical Review, Cotiviti (formerly Verscend)

The Opioid Epidemic: Early Identification and Intervention
Tuesday, October 30
10:00 am – 11:00 am
Presented by HMS, A NHCAA Platinum Supporting Member

According to the Centers for Disease Control (CDC), drug overdose deaths have been on the rise for nearly two decades; and since 1999, opioid-related overdoses have quadrupled. Nearly half of opioid overdose threats involve a prescription medication. Identifying the occurrences of opioid misuse and healthcare system gaming is the first step in preventing abuses and overdoses. This session will provide information about how data analytics can provide indicators for opioid abuse and improper and fraudulent prescribing patterns. The session faculty will review current best practices and new methodologies available for identifying doctor shopping, pill mills, drug seeking emergency room visits and medical identity theft.

This presentation will assist investigators in:

  • Identifying the occurrences of opioid misuse and healthcare system gaming is the first step in preventing abuses and overdoses.
  • Determining how data analytics can provide indicators for opioid abuse and improper and fraudulent prescribing patterns.

Faculty

Gary Call, MD
HMS Chief Medical Officer, HMS 

Sober homes, rehab facilities, and long term care… Oh my!?!?
Tuesday, October 30
11:15 am – 12:15 pm
Presented by LexisNexis® Risk Solutions, A NHCAA Platinum Supporting Member

Many fraudsters are creating schemes to go after the most susceptible fraud patients. These patients include those suffering from addiction, from some sort of chronic pain, or who have entered the ranks of the forgotten within long-term care facilities. This session will cover the risks associated with patients, providers, facilities, brokers, or other entities or individuals that may be associated with the healthcare payment model.  From the identification of the risks, we will discuss methods that utilize claims analytics to surface those that are behaving outside of the norm and the value of uncovering unknown social and business connections associated with a particular scheme.  Finally, we will focus on identifying methods to uncover quality of care concerns.  

This presentation will assist investigators in:

  • Discussing methods that utilize claims analytics to identify those that are behaving outside of the norm.
  • Determining the value of uncovering unknown social and business connections associated with a particular scheme.

Faculty

Rick Grape
Director, Healthcare Innovation, LexisNexis® Risk Solutions

Tom Figurski
Director of VSIU, LexisNexis® Risk Solutions

Leveraging the Power of AI to Address Fraud, Waste and Abuse
Tuesday, October 30
11:15 am – 12:15 pm
Presented by Change Healthcare, A NHCAA Platinum Supporting Member

Payers are using a variety of ways to attack the significant issue FWA plays in health care spending, but one that shows a promising return is the use of AI technologies. This technology offers new ways to tap into, manipulate, evaluate and leverage huge amounts of data and offers an untold opportunity for insurers to address this monumentally expensive problem. Participants will gain insights into how one company is leveraging AI to uncover real and potential problems resulting from fraud, waste and abuse for its payer customers. Presenters will provide an overview of machine learning for the investigator and analyst, and share real life examples of how this technology is being used to identify aberrant claims for record review at both the Pre-payment and Post-payment phases of the payment continuum. Attendees will understand the potential application and direct benefit that clients are seeing including an expected annualized savings lift of at least 10%.  

This presentation will assist investigators in:

  • Recognizing the value of AI to identify FWA issues.
  • Examining how technology is being used to identify aberrant claims for record review at the pre-payment phase.

Faculty

Louise Dobbe, JD
Director, Payment Accuracy Insights, Insight Record Review, Change Healthcare

Debra Riekkoff
Project Manager, Payment Accuracy Insights, Change Healthcare

Busting the Myths of Successful Pre-pay FWA
Tuesday, October 30
2:15 pm – 3:15 pm
Presented by Cotiviti (formerly Verscend), A NHCAA Platinum Supporting Member

The value proposition for prospectively addressing fraud, waste and abuse (FWA) in the industry has been understood by payers for well more than a decade, yet adoption has been slow at best, or non-existent in some cases. The challenges are real: clinical analyst resources and operational cost constraints; prompt payment guidelines and penalties; provider abrasion; and competing interests among network management, SIUs and claims operations. There are myths standing in the way of overcoming many of these challenges. Join industry experts as they dispel these myths and discuss the different approaches that can improve your pre-payment model while coordinating the competing priorities in your health plan.

This presentation will assist investigators in:

  • Understanding the challenges and myths of pre-pay FWA detection analytics
  • Justifying why post-pay FWA is necessary for pre-pay pattern detection
  • Articulating best practices from payers utilizing multiple pre-pay methods along with post-pay analytics

Faculty

John Neumann, RN
Clinical Consultant, Cotiviti (formerly Verscend)

Erin Picton, AHFI, CFE
Director of Fraud, Waste and Abuse, Cotiviti (formerly Verscend)

Protect Your Plan from Social Media and Digital Fraud Attacks
Tuesday, October 30
3:30 pm – 4:30 pm
Presented by CGI Federal, A NHCAA Platinum Supporting Member

Social and digital are the new risk vectors. Fraud scams, social profiling, account compromise, credential theft, insider threats, you have locked down your networks and email but how are you protecting yourself from social media risks? Find out how fraudsters utilize executive impersonations, social engineering, fake support reps and other scams that can cause financial loss and reputational damage. Learn how you can use real-time monitoring of social media and the deep web to gain intelligence on fraud schemes and take action against them.

This presentation will assist investigators in understanding:

  • Recognizing how real-time social media monitoring can help to fight fraud schemes.
  • Implementing strategies to protect your organization against digital attacks.

Faculty

David Ott
Senior Director, Consulting Services, CGI Federal

Kurt Spear
Vice President, Financial Investigations and Provider Review (FIPR), Highmark, Inc.

Capturing Group and Plan Fraud: Detecting Schemes for Employer Groups, Lines of Business and Regions
Wednesday, October 31, 2018
10:45 am – 11:45 am
Presented by Healthcare Fraud Shield, A NHCAA Platinum Supporting Member

This session will provide an overview of how to detect fraud, waste and abuse (FWA) by examining data grouped in other ways.   FWA analytics can also be used to identify schemes within and across plan contracts, employer groups, lines of business and geographic regions and more by grouping and comparing data by these attributes.   Faculty will walk through real case examples where this approach effectively identified suspect behavior.

This presentation will assist investigators in:

  • Examining how analytics can be used to identify schemes withing and across plan contracts.
  • Discussing how data can be grouped in new ways to identify FWA.

Faculty

Jim McCall, AHFI
Vice President, Client Engagement, Healthcare Fraud Shield

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

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

Policy Insights With Watson:  Applying the Power of Cognitive Computing to Improve Program Integrity
Wednesday, October 31, 2018
1:55 pm – 2:55 pm
Presented by IBM Watson Health, A NHCAA Platinum Supporting Member

To help you get the most from your efforts to fight fraud and program abuse, IBM Watson Health is working to focus the power of Watson™ cognitive computing, combined with marketing-leading PI subject matter expertise to improve investigator productivity and increase the amount of inappropriate claims dollars prevented/recovered.  Join this session to learn how PI innovators are pursuing the use of cognitive computing systems to change the way they interact with and apply policy in support of their program integrity efforts.  The session will include an overview of cognitive systems and the ways in which they can utilize structured and unstructured data, as well as case examples from Medicaid agencies who are working with IBM to apply these cognitive systems towards the goals of improved productivity and ROI.

This presentation will assist investigators in:

  • Learning how PI innovators are pursuing the use of cognitive computing systems to change the way they interact with and apply policy in support of their program integrity effort.
  • Examining how cognitive systems can be leveraged and utilized structured and unstructured data for improved productivity.

Faculty

Mark Gillespie
Offering Management Lead, Program Integrity, IBM Watson Health

David Nelson
Strategy, IBM Watson Health

Healthcare in the Post‐Honesty Era
Wednesday, October 31, 2018
3:05 pm – 4:05 pm
Presented by SAS Institute, Inc., A NHCAA Platinum Supporting Member

Risks to healthcare plans and payers are growing at an exponential rate. They have become complex and multi‐layered, with cyber risks, medical identity theft, and internal threats adding to traditional abuse, fraud and networks. To prevent fraud and increase payment and program integrity in healthcare now that we’re living in a post‐honesty era takes new thinking. This session will first spend time analyzing data that lays out these risks, many of which aren’t on the minds of top executives. With an understanding of the reality of the risks, we will then dive into some ideas for approaches to stem the tide. In this session, we will analyze threats and counters from other industries, including financial services and taxation, discussing a mixed, best‐of‐breed approach to utilizing analytics and continual monitoring in healthcare fraud prevention that is ready to deal with the risks of today and the reality approaching tomorrow.

Faculty

Carl Hammersburg
Manager of Government, Healthcare Risk and Fraud, SAS Intitute, Inc.

BREAKFAST SESSIONS
WEDNESDAY, OCTOBER 31
7:30 am – 8:45 am

Success Drivers of Healthcare Anti-Fraud Efforts
Presented by Fraud Scope, A NHCAA Premier Supporting Member

Industry experts will discuss the main success drivers of an effective anti-fraud effort at your plan. Learn how AI can be used to effectively combat constantly changing fraud schemes automatically while maintaining low false positive rates in both pre-pay and post-pay detection settings. This session will also include discussion of how to enhance collaboration among investigators and analysts by effective sharing of information to drive cases to a resolution in a quicker manner.

Faculty

Patrick Stamm
Principal Advisor, FraudScope

Musheer Ahmed
Chief Executive Officer, FraudScope

Addressing the Outpatient Claim Blind Spot
Presented by SCIO Health Analytics (an EXL Company), A NHCAA Premier Supporting Member

The past decade has seen a dramatic growth in the use of outpatient care. This trend is driven by multiple factors, presents unique challenges, and is not expected to abate. In 2018, the total spend by health plans on outpatient care has grown to the point where, if left unchecked, most health plans risk significant negative financial impacts. This presentation will review key fraud, waste, and abuse issues found in outpatient claims, share precise selection techniques to catch overpayments, and provide examples of applying clinical review techniques to maximize findings.

Faculty

Rodger Smith
Senior Vice President, Payer Solutions, SCIO Health Analytics (an EXL Company)

Shawn Salkeld
Vice President, Healthcare, SCIO Health Analytics (an EXL Company)

Artificial Intelligence Driven MMIS modules
Presented by Digital Harbor

Medicaid is witnessing a transformation driven by Modular MMIS Implementations. The Key to Modularity’s success depends on delivering enhanced Analytics and Improved User Experience to enable Provider and Beneficiary-Centric Systems.  This session will discuss how Artificial Intelligence can provide the core capabilities to enable this change. What if Providers and Beneficiaries can enroll and connect in near real-time and with minimum help. Imagine if, Medicaid Programs can receive near-time alerts on non-compliant beneficiaries, providers or claims and manage their programs through Social Dashboards. We will demonstrate how AI can implement MITA capabilities through “Conversational Applications” enabling even complex Medicaid workflows to become self-service. 

Faculty

Rohit Agarwal
President, Digital Harbor, Inc.

Program Integrity Next Generation:  Leveraging Pre-pay Data to Deliver Better Results
Presented by Optum, A NHCAA Premier Supporting Member

Presenters will review and discuss in detail the integration and implementation of a pre-pay analytic based tool for a commercial health plan.  Discussion will include details related to the relationship between the client and vendor during and after implementation, how to leverage SMEs to create new and unique custom analytics, details regarding the various analytic application methods and integration of a predictive modeling tool to the mix.  The participants will learn about a well-established, successful pre-pay program from analytic build through invoice reconciliation.  Additionally, participants will learn how pre-pay processes can and should co-exist with a post pay program and benefit in both the short and long term.

This presentation will assist investigators in:

  • Discussing how to integrate a pre-pay analytic based tool for a commercial health plan.
  • Examining the how the vendor’s SME can help to create new custom analytics.

Faculty

Blair Marendt
Operations Manager, Blue Shield of California

Brian Fisher
Commercial Payment Integrity Business Lead, Payment Integrity Government Solutions, Optum

Lisa Cornish
Associate Director of Payment Integrity, Optum

Using AI Intelligently to Fight Healthcare Fraud: Global Case Studies
Presented by Shift Technology

As everyone knows, healthcare systems vary greatly by country. Insurers face different types of fraud, waste and abuse within each system, yet they boil down to a number of consistent patterns that arise from the reimbursement structure in each setting. By looking at data across major insurers globally it is possible to observe common points and differences. In this session we will walk through a detailed comparative analysis of healthcare insurance fraud, waste and abuse detection through examples in the U.S., Europe, and Asia. We will describe targeted behaviors, the data used to detect them, and the actions taken by insurers. Lastly, we’ll explain how AI, applied the right way, helps in this fight.

Faculty

Eric Sibony
Co-Founder and Chief Scientific Officer, Shift Technology