Conference Sessions

Choose from more than 60 sessions and 3 workshops organized in 7 tracks designed to provide the latest techniques for fighting health care fraud and information on identifying emerging trends leading to successful fraud prevention. All session are taught at Level II.

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.

Download the Full Conference Agenda to see all available programs.


Prescription Drug Fraud Schemes
Wednesday, 10:00 am - 11:15 am
View Description Examine today’s emerging and newly approved drugs and how they may be the focus of tomorrow’s investigations. Faculty will explore the paradigm shift to non-controlled drug diversion and look closely 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
Operations Officer, Investigations Unit, U.S. Department of Health & Human Services, OIG

Facilities Fraud: Breaking Down the Acute Care Hospital Scheme
Wednesday, 10:00 am - 11:15 am
View Description The faculty will discuss how to identify the scheme, including what billing procedure/revenue codes to review, place of service codes and which bill type to look for. Faculty will also offer insights for current cases in Florida to illustrate how to identify who may be involved in the scheme from hospital staff and independent clinical labs to management companies. This session will also provide insight as to what actions were taken to deter and prevent additional exposure.

David Goldner
Federal Employee Healthcare Benefit Program Senior Investigator, Florida Blue

Jose M. Ramos, AHFI
Manager, Special Investigation Unit (SIU), Notary Public State of Florida, Florida Blue

Best Practices in Conducting Onsite Inspections
Wednesday, 10:00 am - 11:15 am
View Description Effectively conducting onsite inspections requires a specific set of skills and techniques. This session will discuss key elements including appropriate preparation, documentation, collection of evidence and observation of customer activity and staff. Attendees will walk away understanding best practices in preparing for a site visit such as developing inspection forms and/or checklists, examining the statutory and contractual provisions, and knowing what equipment is appropriate to use. In addition, faculty will offer best practices in documentation and evidence collection. Attendees will hear examples of what has worked and lessons learned so that adjustments and changes can be made to your own work. The examples provided will also demonstrate next steps with successful referrals to prosecutorial agencies, licensing boards, and state/federal regulators.

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

Danielle Wilson
Manager, SIU, UnitedHealthcare Investigations

A Review of Current, Emerging and Potential Dental Fraud Schemes
Wednesday, 10:00 am - 11:15 am
View Description Dental fraud, waste and abuse schemes have traditionally presented themselves in various forms. 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. Keeping the past, current and emerging schemes in mind, along with concern for future schemes can be a challenge for investigators when identifying/investigating fraud, waste and abuse. This quick paced session in a 'study guide' survey type format will provide a review of current, emerging and possible upcoming schemes and/or coding irregularities across a wide variety of clinical and non-clinical areas.

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

Jason Coomer, DDS
Investigator, Humana

Federal Agencies Examine the Trends and Discuss the Priorities
Wednesday, 10:00 am - 11:15 am
View Description Leaders from key law enforcement agencies focusing on health care fraud will offer insights on their agency’s priorities, trends, and future initiatives. Through this panel discussion, attendees will hear about recent successes in the fight against health care fraud and efforts to curb criminal activity. Attendees will learn about the unique approaches of each organization, as well as the commonalities among the leading law enforcement agencies working to fight health care fraud.

Joseph Beemsterboer, Chief - Healthcare Fraud Unit, U.S. Dept. of Justice, Criminal Division, Fraud Section

Gary Cantrell, Deputy Inspector General for Investigations, U.S. Dept. of Health & Human Services, Office of the Inspector General

Thomas Daly
Acting Unit Chief, Health Care Fraud Unit, Federal Bureau of Investigation

Medicaid Managed Care: Challenges and Opportunities of Investigating
Medicaid Fraud

Wednesday, 10:00 am - 11:15 am
View Description Developing a consistent approach to fight fraud between the Medicaid Program Integrity (PI), Medicaid fraud control units (MFCUs), and Medicaid Managed Care Organizations (MCO) is critical to fighting health care fraud. Hear from leaders from the public and private sectors about best practices in communication and successful referrals, as well as ways to work through challenges. 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.

Katherine M. Leff, RN, CLU, ALHC, CFE, AHFI, CHC, Director, Special Investigations, CareSource 

John L. Maynard, CPA
Chief, Program Integrity, Ohio Department of Medicaid

Keesha Mitchell
Section Chief-in-Charge, Health Care Fraud Section, Ohio Attorney General's Office

Lloyd S. Early
Special Agent-In-Charge, Health Care Fraud Section, Ohio Medicaid Fraud Control Unit

Transforming How SIUs Optimize Resources Through a
Provider Decision Quadrant
Presented by Verscend, an NHCAA Platinum Supporting Member

Wednesday, 10:00 am - 11:15 am
View Description Many SIUs are constrained due to resource limitations and are often plagued by a high volume of cases with low yields. Investigations can be resource intensive and time-consuming, and different scenarios of fraud, waste, and abuse (FWA) call for varying degrees of action. By mapping FWA factors to a decision quadrant, investigators can effectively decide where to allocate their time with a priority for the most high-yield scenarios. The presenters will demonstrate how to increase ROI through maximizing efficiencies and how resources can be optimally allocated to combat FWA, meet compliance requirements, and minimize provider abrasion.

Mark Isbitts
Vice President, Product Management, Verscend Technologies

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

Substance Abuse Fraud Scheme
Wednesday, 11:30 am - 12:30 pm
View Description Substance abuse treatment facilities have popped up across the country as a result of the opioid epidemic and the enactment of the Affordable Care Act and Mental Health Parity. Presenters will discuss common fraud schemes and quality of care issues related to substance abuse treatment providers. Patient brokering, unlicensed clinicians, misrepresentation of services, kickbacks, fee-forgiving and lack of medical necessity will be addressed. This course will provide an overview of the levels of care related to substance abuse treatment, issues related to drug testing, common fraud schemes and resolution strategies.

Deanna Hollwedel, AHFI
Fraud Manager, Cigna

Barbara Center, MD
Psychiatrist, Prest & Associates, Inc.

Michael Goldfarb, Esq.
Fraud Manager, Cigna

Building your Presentation Skills: Tips, Tricks and Best Practices (Repeat)
Wednesday, 11:30 am - 12:30 pm
View Description This session focuses on tips and tricks for dynamic presentations and public speaking engagements. Whether a new investigator or experienced senior manager – this session will help the attendee master critical speaking skills complemented by effective MS Powerpoint presentations. This session will also cover presentations most commonly utilized by anti-fraud personnel including case presentations to attorneys, and large audience engagements for investigative partners. Learn techniques utilized by successful speakers, and transform your own speaking style to become a persuasive and effective communicator.

Jennifer Trussell
Chief Investigator, Office of Counsel to the Inspector General, U.S. Department of Health and Human Services, Office of Inspector General

CMS Update: Initiatives and Progress in Health Care Fraud
Wednesday, 11:30 am - 12:30 pm
View Description 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
Acting Director, Center for Program Integrity (CPI), U.S. Dept. of Health & Human Services, CMS

Telemarketing and Telemedicine: The New Way of Prescribing
Wednesday, 11:30 am - 12:30 pm
View Description This session will discuss the expanding schemes related to DME and pharmacy mail-order and how telemarketers are using telemedicine to their advantage. The Speakers will discuss what red flags to look for in the data, how to follow-up on leads, steps to take during the investigation, suggestions for prevention of future loss and obstacles related to current policy and legal statutes. Discussion of ongoing investigations and case examples will be part of the presentation.

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

Susan Collare, CFE, AHFI, CPhT
Senior Fraud Analyst, Financial Investigations & Provider Review, Highmark Blue Shield

Jaime Wetzel
Senior Fraud Analyst, Highmark Blue Shield

Eric Rubenstein
Special Agent, Office of the Inspector General, U.S. Dept. of Health & Human Services

Surveillance and Strategies for LTC, Disability and Workers Compensation Claims
Wednesday, 11:30 am - 12:30 pm
View Description This session will examine the similarities between Disability and Workers Compensation claims where the investigative focus is often on a medical issue and a claimed injury. However, Long Term Care (LTC) investigations often focuses on the care giver and not the subject on claim. All three have similarities related to investigation and surveillance and those are general activity noted. Faculty will describe and give real examples of successes and some challenging scenarios encountered while investigating these types of claims. Faculty will also discuss the importance of making a quality and detailed referral/assignment that will assist in leading to a positive outcome. Finally, the faculty will discuss some strategies related to a new tool available within the industry that has proven to be a valuable addition to the investigators toolbox.

Patrick Burke, CFE, CIFI, FCLA, CATI
Senior Vice President-Partner, The Robison Group Investigative Solutions

Home Health Fraud Scheme with Medicare Beneficiaries: A Case Study of
Kickbacks and Fraudulent Services

Wednesday, 11:30 am - 12:30 pm
View Description In this session, attendees will learn the details about the largest criminal investigation and prosecution of a single physician, resulting in the submission of over $400 million in fraudulent claims to the Medicare and Medicaid programs. Hear about the phases of the investigation of Dr. Jacques Roy beginning with the initial innovative and proactive data analytics. Attendees will hear about the complex investigation which led the HEAT/ Strike Force team in Dallas to collaborate extensively with the Centers for Medicare and Medicaid Services (CMS), Medicare contractors, state licensing officials, state Medical Boards and Nursing Boards, homeless shelters, local police departments, the Drug Enforcement Administration, Immigration and Customs Enforcement, and others. This is a substantive case which led HHS/OIG/OI to work with CMS to develop payment system edits related to home health agency billing that would flag suspect claims at their submission.

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

Thomas Cook
Special Agent, U.S. Dept. of Justice, Federal Bureau of Investigation

Using Data to Uncover Fraud on the Exchange
Presented by LexisNexis, an NHCAA Platinum Supporting Member

Wednesday, 11:30 am - 12:30 pm
View Description 2017 once again finds the healthcare industry in a state of constant change. Three trends especially impacting health plans and their weapons for fighting Fraud, Waste and Abuse include; the movement to paying for quality as opposed to fee-for-service, the expansion of Medicaid and dawn of the Exchange era, and how the economics for brokers have changed, requiring a health plan to keep a close eye on their new enrollees. Fraudsters understand that these changes make gaming a claims analytics system much more difficult. However, it also leaves health plans more vulnerable to identity-based fraud. This session will examine the gaps in health plan operations that need to be addressed and how a health plan can use identity data and profiles to combat these new schemes. Faculty will also discuss strategies that payers can implement to avoid millions in claims payments, broker commissions and fines, while adhering to Federal compliance standards.

Rich Morino
Director, Strategic Solutions, LexisNexis Health Care

Rick Grape
Director, Market Planning, LexisNexis Health Care

Reducing Medical Billing Waste and Abuse with Technology and Expertise
Presented by MultiPlan, an NHCAA Platinum Supporting Member

Wednesday, 11:30 am - 12:30 pm
View Description With the increasing complexity of medical bills, a high volume of waste and abuse is undetected by solutions that rely only on automated claim review. Simple coding errors that can be found by technology account for only a fraction of claim issues. Incorporating an expert prepayment review doubles your opportunity to avoid paying for inappropriately billed charges while still observing prompt-pay requirements. In their presentation, the faculty will discuss successful solutions that combine technology with human expertise to root out waste and abuse in medical bills.

Cherise Skeba
Senior Vice President, Client Services, MultiPlan

Christopher Dorn
Vice President, Payment Integrity, MultiPlan

Using Clinical Skills and Data Techniques in Fraud Investigations:
an Interactive Approach

Wednesday, 2:30 pm - 3:30 pm
View Description This session will address Allergy Testing and Immunotherapy, one of the latest "schemes" in Florida and other areas in the country. After providing background information on the scheme, examples of data reports will be utilized to highlight targeted data elements used in case development, and to demonstrate the nuances of each data element. Faculty will use redacted medical records as an exercise in identifying discrepancies, "hidden" fraud, and as a method of verifying correct coding and billing. Examples of how and when to utilize clinical staff and other team members in clarifying information, supporting and bolstering case development, and becoming knowledgeable about the clinical aspects of the case will be discussed, as well as tips for developing a law enforcement referral.

Cynthia Dangerfield, RN, CPC
Senior Medical Review Nurse, SIU, Florida Blue

Missouri v. Corrine A. Dale, LPC: an MCO Medicaid Fraud Case Study
Wednesday, 2:30 pm - 3:30 pm
View Description This session is a case study discussing State v. Dale, the first Medicaid Fraud prosecution in Missouri to use MCO claims as evidence of fraud. In the context of this case, the presenter will discuss the unique issues and potential pitfalls of working with multiple MCOs to build a case, as well as the challenges intrinsic to investigating and prosecuting behavioral health providers. Faculty will discuss the intricacies of investigating behavioral health providers who file claims for services not provided and developing and presenting a criminal case of this kind to the grand jury for indictment.

Amanda Burrows
Investigator, Missouri Attorney General's Office, Medicaid Fraud Control Unit

Hospice Fraud Trends
Wednesday, 2:30 pm - 3:30 pm
View Description This session will examine current trends in hospice fraud and how to investigate a hospice agency. Faculty will address "red flags" found in hospice claims data and discuss significant evidence obtained from beneficiary interviews. Attendees will hear about real-world examples from hospice investigations, including a current undercover operation involving a hospice owner and a kickback scheme, and a recent case against California Hospice Care, LLC. (CHC). Faculty will also discuss the lessons learned from their successes and pitfall, the tactics used to illicit incriminating statements and confessions from various suspects. Thebenefits of working joint cases with other law enforcement agencies, and various investigative techniques that can be used to investigate a hospice case, including undercover operations, surveillance, consensual monitoring, claims analysis, and financial analysis will also be addressed.

Alison Davis
Special Agent, U.S. Dept. of Health & Human Services, OIG-OI

Eric Froeschner
Special Agent, California Department of Justice, Bureau of Medi-Cal Fraud and Elder Abuse

Dental Fraud: An Investigator’s Perspective
Wednesday, 2:30 pm - 3:30 pm
View Description In this session, faculty will discuss the importance of communication between Special Investigation Units and law enforcement in conducting successful health care fraud investigations, specifically dental fraud investigations. The session will use actual case examples and discuss investigative methods to demonstrate different types of dental fraud. The case examples will include the use of claims data, x-rays, and interviews, and discuss the advantages and disadvantages of these tools. Faculty 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.

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

Sober Home Fraud and Patient Harm
Wednesday, 2:30 pm - 3:30 pm
View Description This presentation will focus on the struggles of sober homes, and the fraud and patient harm associated with the entire drug/alcohol/rehab industry. Participate in this session and learn about the recent prosecutions in south Florida of Kenneth Chatman and Reflections Treatment Center in Margate, Florida. The speakers will offer insight on the investigation, billing schemes, and the legal and undercover challenges faced by law enforcement when prosecuting these types of cases (the need for a Title 42 court order, etc).

JIll Maroney
Senior Special Agent, Amtrak, Office of Inspector General

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

Maria Guerrero
Sr. Investigator, Special Investigation Unit, FloridaBlue

Ann Marie Villafana
Assistant United States Attorney, U.S. Attorney’s Office, Southern District of Florida

Garrett Shohan
Senior Investigator, Special Investigations Unit, Aetna

The Opioid Epidemic: from the Emergency Room to a National Emergency –
Physician and Investigative Perspectives
Presented by General Dynamics Health Solutions, an NHCAA Platinum
Supporting Member

Wednesday, 2:30 pm - 3:30 pm
View Description From evolving perspectives on pain management to over-prescription and genetic predisposition to addiction, many factors have led to the worsening U.S. opioid epidemic. This session explores the increase in prescription opioid availability, including clinical approaches that have helped drive the crisis. An emergency room physician will share insights on medical factors contributing to opioid overuse and abuse, providing an important understanding of their impact on the epidemic’s scope, and with relevant considerations for fraud schemes. Faculty will discuss common techniques, behaviors and fraud schemes used to acquire and supply more drugs to meet demand, and will review effective data mining techniques to help identify schemes. Key Federal and State intervention strategies designed to help reduce opioid abuse will also be reviewed, and a physician will share further medical perspectives on how the crisis can potentially be alleviated.

John Maguire, MD
Chief Medical Officer, General Dynamics Health Solutions

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

A Cognitive Approach to Healthcare Fraud
Presented by Truven, an IBM Company, an NHCAA Platinum Supporting Member

Wednesday, 2:30 pm - 3:30 pm
View Description With all of the on-going changes in the health care environment, payers continue to face challenges in effectively managing the risks associated with a significant shift from a fee-based to a value-based model. With the shift to hybrid payment systems, it is even more important to ensure payment accuracy and embrace new cognitive capabilities in order to react to emerging schemes. Attendees interested in developing a more cognitive approach to value-based payments can participate in this session to learn about secured payment transactions in a secured cloud environment. Faculty will share insights into new behaviors such as; duplicate patient records, “double-dipping” from other programs for same services, and other unique schemes that would have otherwise been overlooked by the traditional hybrid payment system today.

Interviewing in Non-Typical Situations
Wednesday, 3:45 pm - 4:45 pm
View Description Today’s Health Care Fraud investigator may find themselves speaking to individuals that require special and unique techniques beyond the typical interview in order to obtain information that is relevant and credible. Senior citizens, minors, or persons with barriers to communication may be crucial witnesses with valuable information. This presentation will address non-typical interview situations, offering factors to consider and strategies for successful interviews in these situations. While the program is focused towards the private-sector investigator in pursuit of evidence of inappropriately paid claims, the identification of potential patient safety issues will also be discussed.

Kenneth Cole, AHFI, CFE, CPC
Manager of Special Investigations, Healthcare Fraud Shield

Best Practices in Responding to CMS Memos and Audit Tracers
Wednesday, 3:45 pm - 4:45 pm
View Description This session will explore the Kaiser Permanente’s end-to-end process for responding to CMS Memos. The audience will learn how Kaiser identifies providers for potential over prescribing/dispensing of opioid medications and the subsequent clinical review process, which has led to multiple NBI MEDIC referrals by the SIU. Faculty will share how this process assisted in their response to a recent CMS Compliance Program Effectiveness Audit where the selected FWA tracer was an investigation that resulted from a CMS Quarterly High Risk Pharmacy Assessment.

Tamara Neiman
Director, National Special Investigations Unit, Kaiser Permanente

Mark Horowitz, RPh
Senior Manager, Kaiser Permanente

Behavioral Health Schemes: Psychological Services Medicare Fraud Case
Wednesday, 3:45 pm - 4:45 pm
View Description The faculty in this session will illustrate how to investigate behavioral health schemes through a recent case involving two psychological services companies: Nursing Home Psychological Services (NHPS) and Psychological Care Services (PCS). NHPS and PCS contracted with nursing homes in LA, MS, AL, and FL in order to repeatedly perform unnecessary psychological testing on the residents. This session will equip attendees with investigative techniques to use when multiple fraud schemes are involved and the case is largely historical in nature. In addition, faculty will demonstrate how to use billing data trends and analytics in an investigation and trial.

Jennifer Terry
Special Agent, U.S. Dept. of Justice, Federal Bureau of Investigation

Shannon Goodwin
Special Agent, U.S. Dept. of Health & Human Services Office of the Inspector General

Substance Abuse Treatment: How to Get the Records You Need Without
Violating Federal Law

Wednesday, 3:45 pm - 4:45 pm
View Description Did you know there is a federal statute that governs the disclosure of records of substance abuse treatment? Did you know the regulations governing the disclosure of substance abuse treatment records were substantively updated in February 2017 for the first time in more than 29 years? Substance abuse treatment records can be very useful in investigating and prosecuting many different types of cases including illegal prescribing by doctors and fraud committed by clinical laboratories, Suboxone and methadone practices, and transportation companies. However, the process for obtaining substance abuse treatment records legally is not always clear and questions about whether and how to obtain such records can paralyze investigations.

Stephany Collamore
Assistant Attorney General, Mass. Attorney General's Office

Nita Klunder
Assistant Attorney General, Mass. Attorney General's Office

Embrace the Chaos: How One Man Fraudulently Billed $100 Million
Wednesday, 3:45 pm - 4:45 pm
View Description This session will focus on a large, complex workers’ compensation investigation involving Peyman Heidary. The speakers will cover the investigation, organization, and prosecution of this large-scale case, with specific focus on the paths of injured workers, the flow of money, and the ways a provider network can disguise fraudulent billing. Attendees will hear about the various theories of prosecution and the importance of obtaining organized data from all insurance companies in an efficient manner while developing partnerships with SIU's.

Erika Mulhere
Deputy District Attorney III, Deputy District Attorney, Riverside County District Attorney's Office

Matt Murray, DDA IV
Deputy District Attorney, Riverside County District Attorney's Office

Big Fish, Deep Waters: Proven Fraud Solutions for Maximum SIU Results
Presented by HMS, an NHCAA Platinum Supporting Member

Wednesday, 3:45 pm - 4:45 pm
View Description SIU investigators know many SIUs depend on referrals. Unfortunately, this practice results in the team's recovery opportunities mainly getting the small fish, the lesser cases with little effect in the overall ocean of fraud. What if you had the tools to challenge the status quo and cast the net to catch the bigger fish – those high quality cases that really make a difference? In this presentation, using a combination of analytics, algorithms, and a new scheme model, the faculty will describe how successful analytics can become the new model for best practices in SIU. They will provide case study examples of its success, along with the steps SIU investigators can take to create proactive solutions in building a robust program integrity plan.

Annette McKay
Regulatory Compliance Manager, HMS

Ed Hewitt
Program Integrity Solution Consultant, HMS



Investigating Compound Rx FWA to Contain Costs and Improve Safety
Presented by SCIO Health Analytics, an NHCAA Premier Supporting Member

Thursday, 7:45 am - 9:00 am
View Description The past decade has seen a dramatic growth in the amount of FWA and overpayments related to compounded medications. Although they represent a small portion of overall pharmacy claims, they have a disproportionate amount of errors and waste as compared to traditional claims. Ensuring proper compound procedures, billing accuracy and proper payment for these claim types is often difficult due to data limitations that restrict effective selection, a reliance on manual auditing, and advanced fraudulent techniques used by pharmacies. Join experts in health care fraud, as they discuss how to develop a program to identify inaccurate claims and prevent FWA via a three-pronged approach of edits and prior authorization, FWA identification and recovery, and pharmacy education. In just 4 months, our program identified $3.5 million in potential FWA and recovery, and improved clinical safety by reducing over- and under-dosing.

Rodger F. Smith, Jr., JD
Senior Vice President, Payment Integrity, SCIO Health Analytics

Rena Bielinksi, Pharm.D. AHFI
Senior Vice President, Strategic Accounts, SCIO Health Analytics

Battling the Opioid Epidemic through Innovation, Enhanced Awareness &
Community Commitment
Presented by MedFax

Thursday, 7:45 am - 9:00 am
View Description Hear how one community is battling against opioid addiction by leveraging data analytics, technologies and community partnerships. Speakers will talk about how they are working within the State of Maryland to break the addiction cycle and overcoming the Opioid epidemic that has taken hold in our nation, including leading-edge methods such as Addiction-Proclivity Predictive Analytics and Continuous Provider Monitoring to know each-and-every prescriber, validate prescribing status/authority and identify suspicious prescribing scenarios. The speakers will share how they are leveraging inspirational commitment, innovative trends, predictive analytics and unprecedented provider data monitoring to make this objective a reality.

Kevin Bingham, ACAS, MAAA
Principal, Deloitte Consulting

William K. Moss, JD
Executive Vice President, TruthMD LLC

Thomas Phelan, CPA
President & CEO, Chesapeake Employers Insurance Company

Artificial Intelligence meets Predictive Analytics – Transforming the business
of Fraud Prevention
Presented by Digital Harbor

Thursday, 7:45 am - 9:00 am
View Description U.S. Healthcare is poised to undergo the most significant cost transformation in modern History. Over the next decade the health care industry would need to provide increased coverage with fewer dollars. To accomplish this will require game-changing processes and technologies. This session will discuss next-generation break through platform – Social Enterprise Technology (SET) that fuses Artificial Intelligence, Business Intelligence and Collaborative Intelligence. Providers can enroll in weeks’ vs months using self-service Portals and real-time screening technologies. Members can be connected to optimized services with 360 degree views, voice driven provider directories and Personal Health Assistants. Plans can detect improper payments through real-time monitoring, and manage their programs though social dashboards.

Rohit Agarwal
President & Chief Innovations Officer, Digital Harbor

Leveraging State-specific Medicaid Fraud and Policies to Improve FWA Operations
Presented by Optum, an NHCAA Premier Supporting Member

Thursday, 7:45 am - 9:00 am
View Description The presenters will review and discuss in detail how to optimize state-specific Medicaid policies, as well as fraud, waste and abuse investigations to benefit Medicaid Managed Care (MCO) plans. Algorithms utilized in the Medicaid Fee for Service can translate into savings for MCOs. Sharing investigative tools, investigations and experiences accelerates savings for both the state and MCOs. During the presentation, the participants will learn about successful joint algorithms, auditing methods and sharing successes between stakeholders. Modeling method, common and uncommon state regulations, and stakeholder’s policy manuals will be reviewed, including examples of combined investigations, algorithm results, and a fraud case study. The goal is for attendees to be able to use at least a couple of auditing ideas from this presentation and potentially coordinate similar stakeholder opportunities in their own state.

Christi Wilcoxson
Project Manager, Optum Payment Integrity Government Solutions

LaRhanda Trammell, MPA, MBA, HCAFA
Associate Director, Program Integrity, Evolent Health

Hospital Pass Through Lab Billing
Thursday, 10:30 am - 11:45 am
View Description As the industry continues to focus on decreasing the cost of healthcare and bringing those savings back to the consumer, it is natural to focus on areas of increased spend and analyze the root cause of the increase, including laboratory service schemes. Like many schemes, this one has continued to evolve. The most recent version of this schemes is between hospitals and laboratories, for the express purpose of funneling money to “known” labs who are no longer receiving reimbursement directly from insurers. This session will use actual cases to demonstrate how the scheme works from Setup, Contracts/Agreement, Provider/Patient brokering, misrepresentation of services, kickbacks, fee-forgiving and lack of medical necessity.

Kelly Tobin, CFE, AHFI
SIU Director, UnitedHealthcare Investigations

Joseph Popillo, AHFI, CPC-A, CPCO
Escalations Director, Fraud, Waste and Abuse, UnitedHealthcare

Emerging Issues in Medicare Fraud
Thursday, 10:30 am - 11:45 am
View Description 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, emerging trends, data analysis, special initiatives, and specialty areas affecting Medicare and Medicaid.

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

Comfortably Numb: A Parallel Investigation into Fraudulent Nerve Blocks and
Diverted Opiates

Thursday, 10:30 am - 11:45 am
View Description On May 5, 2016, Dr. Paul DeWeese, a former Michigan State Representative and emergency room doctor, pleaded guilty to making false statements related to a health care matter in connection with his fraudulent manipulation of electronic medical records. The DeWeese investigation started as a qui tam, developed into related civil and criminal cases, and spawned a separate state licensing action, all of which had to be managed and organized by the prosecution team. This session will offer valuable insights into navigating multiple parallel proceedings while investigating a host of trending health care violations, including the falsification of electronic medical records, billing insurers for experimental procedures, and the diversion of prescription drugs under the guise of medication-assisted substance abuse treatment.

Christopher Rodolico
Special Agent, U.S. Dept. Of Justice, Federal Bureau of Investigation

Adam Townshend
Assistant United States Attorney, United States Attorney's Office

Jacqueline Lack
ACE Contract Investigator, United States Attorney's Office

Kimberly Orlando
Postal Inspector, U.S. Postal Inspection Service

Multi-agency Case Study: Dismantling a Pill Mill
Thursday, 10:30 am - 11:45 am
View Description Physicians Pain Specialists of Alabama, a pain management clinic in Mobile, Alabama was part of a criminal enterprise that generated millions by over-prescribing opioids, submitting fraudulent billing claims and engaging in illegal kickback schemes. This OCDETF case, jointly investigated by the FBI and DEA, was the first nationwide in which a doctor was convicted by jury of RICO in a “pill mill” investigation. The prosecutors will describe how they presented the twenty-two count RICO Indictment related to Healthcare Fraud, multiple Drug Violations, Violations of the Anti-Kickback Statute, Money Laundering and Mail/Wire Fraud. You will learn the types of evidence used at trial and how the Government developed its witnesses to obtain guilty verdicts on twenty-one of the twenty-two counts. They will also discuss current legal issues involved in healthcare fraud investigations such as criminal versus civil, privacy issues requiring court authorization and the use of undercover techniques in a clinical setting.

Michael Burt
Special Agent, U.S. Dept. of Justice, Drug Enforcement Administration

Amy White
Special Agent, White Collar Crime Squad, U.S. Dept. of Justice, Federal Bureau of Investigation

Deborah Griffin
Assistant United States Attorney, Southern District of Alabama

Kevin Downey
Diversion Investigator, U.S. Dept. of Justice, Drug Enforcement Administration

Christopher Bodnar
Assistant United States Attorney, Southern District of Alabama

Supplemental Insurance Schemes & Scams: The Impact of an Agent/Broker
Thursday, 10:30 am - 11:45 am
View Description This session will focus on agent schemes and scams occurring in supplemental insurance products from New Business to Claims. The presenters will discuss cross-sales contamination and the impact to customers, as well as red flags to identify purely bogus applications. The presenters will also demonstrate suspected claim fraud involving the agent from two points of view – the participation of an agent by assisting multiple customers with the filing of multiple accident claims, and examples of when an agent, who is also the customer, is suspected of committing claim fraud. Attendees will learn new ways to use complaint patterns and data mining to identify potential application fraud and how to examine claim data linked to the agent to identify possible multi-customer, multi-claim fraud.

Kristi Colbert
Manager, Special Investigations Unit, SureBridge Insurance

Elizabeth Bullinger
Investigator, Special Investigations Unit, SureBridge Insurance

The Curious Case of the Nightburners
Thursday, 10:30 am - 11:45 am
View Description This was a joint investigation involving the HHS-OIG, IRS-CID and the MFCU. Rose Umana was the owner and operator of Vision Healthcare Services (VHS). This session will detail the extent (falsified documents, money laundering, creation of false timesheets) to which Umana and others at Umana’s direction, attempted to defraud Medicaid out of $1.1 million dollars. Additionally, the case will highlight the importance of strong working relationship between state, federal and private industry, to combat healthcare fraud.

Michael Williams
Special Agent, Office of the Inspector General, U.S. Dept. of Health & Human Services

Jennifer Snerr
Supervisory Special Agent, Office of Attorney General, Commonwealth of Pennsylvania

Prepayment: Understanding the Prepayment Process and Challenges from A to Z
Presented by Healthcare Fraud Shield, an NHCAA Platinum Supporting Member

Thursday, 10:30 am - 11:45 am
View Description This session will explore the prepayment process from beginning to end. Attendees will learn about the different methods (both targeted and predictive) driving the decision to monitor activity in a prepayment setting. This session will also cover best practices as well as common obstacles payers face during prepayment. Finally, the session will include a prepayment case study.

Aneta Andros, MS, AHFI
Analytics Manager, Cigna

Megan Dimmock
Client Engagement Specialist, Healthcare Fraud Shield

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

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

Behavioral Analysis Techniques to Uncover Complex Fraud Schemes
Thursday, 1:00 pm - 2:00 pm
View Description The key to discovering fraud, waste and abuse risk is to developing a methodology that enables the data to pose the questions, not to have you ask the data. With so many providers, procedures, diagnoses and related nuance to billing, quickly identifying the areas of highest risk that justify investigative resources is critical to success. In this session, faculty will demonstrate how to develop a Behavioral Classification System to understand fraud risk and hear about simple analytic methods that leverage the classification system using simple "free" tools (e.g. Excel/Access).

James McCall, AHFI
Director, Analytic Innovation, Anthem, Inc.

Planning Ahead: Best Practices to Maintain Medicare and Medicaid Audit

Thursday, 1:00 pm - 2:00 pm
View Description Attendees will walk away from this session with the skills necessary to create a solid plan for future Medicare or Medicaid regulatory audits. Attendees will also gain valuable insight into audit preparedness and concrete tips to bring back to the office to develop their own audit readiness plan. This session will offer insight and best practices on what to expect, how to maintain case documentation properly in order to be prepared for incoming audits, and simple daily case note habits to prevent last minute scrambling during an audit. Attendees will walk away with a better understanding of how to leverage your case management system to maximize efficiency and important themes to incorporate into Policies and Procedures and Desk Level Procedures for use by your staff.

Paulina Davis, CPC
SIU Manager Medicare, Anthem, Inc.

Jennifer Cregg, AHFI, CPC
Investigator Lead, Anthem, Inc.

Physical Therapy Fraud Scheme: Utilizing Undercover Operations to Expose
Health Care Fraud

Thursday, 1:00 pm - 2:00 pm
View Description Gain insights on a collaborative effort between law enforcement and a private insurance company to expose a physical therapy health care fraud scheme. Department of Health and Human Services, Office of Inspector General (HHS/OIG) Special Agents collaborated with Blue Cross Blue Shield of Arkansas Special Investigations Unit (BCBS-SIU) wherein the SIU was able to provide an undercover benefit card. Attendees will learn about the development and investigation of this type of case, and gain insights on the detailed planning of undercover operations and resulting recordings. In addition, attendees will learn how this type of evidence is used when charging subjects.

Jeffrey Hannah
Special Agent, U.S. Dept Health & Human Serivces, Office of Inspector General

Shannon Goodwin
Special Agent, U.S. Dept Health & Human Services, Office of Inspector General

Tammy Chastain, AHFI, HCAFA, EMT-B
Senior Investigator, Arkansas Blue Cross Blue Shield

Importance of SIU Involvement in Non-Par and Par Provider Contracting
Thursday, 1:00 pm - 2:00 pm
View Description The contracting processes between participating (par) and non-participating (non-par) providers sets forth the terms and conditions of participation for both the payer and the provider. In this session, participants will learn the importance of SIU having a hands-on approach in analyzing all provider applications submitted. Most importantly, SIU can provide valuable insight by identifying potential fraudulent applications and predicting changes in provider behavior.

David S. Popik, AHFI, CFE
Sr. Director, SIU/Physician Ancillary, Florida Blue

Dawn Murphy, AHFI, CPC, COC, CPC-PM
Senior Manager, SIU, Florida Blue

Project Oxy Crush: The Investigation of Dr. Jaime Guerrero
Thursday, 1:00 pm - 2:00 pm
View Description Dr. Jaime Guerrero was a prolific opioid over-prescriber with offices in Louisville, Kentucky and Southern Indiana. An investigation by HHS-OIG, DEA, FBI and two state Medicaid Fraud Control Units revealed that Guerrero was personally responsible for several patient overdose deaths. He was convicted of drug diversion, health care fraud and money laundering relating to his pill mills. This session will cover a number of topics helpful to the health care fraud investigator, including how to collect medical evidence of over-prescribing, such as autopsy and toxicology reports, as well as how to interview patients and their family members who were victims in this case. The overarching themes will be the importance of teamwork in complex investigations and the epidemic of opioid addiction in states like Indiana and Kentucky. This session will also offer a roadmap for investigators working similar cases.

Chris Covington
Assistant Special Agent in Charge, U.S. Dept. of Health & Human Services, Office of Inspector General

Spencer Melton
Special Agent, U.S. Dept of Health & Human Services, Office of Inspector General

Oral Sleep Apnea, Appropriateness of treatment based on age, diagnosis
and other data analytics

Thursday, 1:00 pm - 2:00 pm
View Description This session will demonstrate various methods used to identify appropriateness of care associated with Obstructive Sleep Apnea (OSA) and various related conditions and determine through thorough submitted claim data analysis, that the treatment was deemed appropriate for the condition treated. It will also highlight durable medical equipment (DME) used to treat obstructive sleep apnea and various sleep related conditions demonstrating appropriate and inappropriate coding combinations. Data will demonstrate coding combinations that should be reviewed for medical necessity and will identify those providers who are performing same day billing to medical and dental plans in an effort to maximize revenue, especially when plans are not linked by products. This session will also demonstrate procedures performed in Surgery Centers and the various impacts those types of services have on Dental and Medical plans in addition to pharmacy plans.

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

Using Analytics to Drive Payment Integrity and Reduce Fraud
Presented by SAS, an NHCAA Platinum Supporting Member

Thursday, 1:00 pm - 2:00 pm
View Description Government and commercial health care markets are in a state of change. Both government agencies and private insurers are driving value by reducing cost, improving outcomes and leveraging data. Enterprise analytics platforms can help integrate results across business areas such as condition management, cost containment, process improvement, audit and fraud investigations. by claims, clinical targeting and revenue optimization. The introduction of analytics based, proactive fraud detection solutions requires examination of fraud case selection and prioritization processes to ensure success. During this session, we will look at a payment integrity approach that delivers results. They will also share case studies demonstrating how analytics can create measurable financial impact. Faculty will focus on the following key disciplines: data management, claims analytics, behavioral analytics and clinical targeting. We’ll examine Locum Tenens physicians as a use case that illustrates how analytics can identify potential abuse and support recovery. 

Ben Wright
Senior Solutions Architect, SAS

Fraud Schemes Involving Pharmacies and Pharmaceutical Wholesalers
Thursday, 2:15 pm - 3:15 pm
View Description Fraud This session provides perspective on a Medicare Part D fraud scheme that involves multiple pharmacies, a pharmaceutical wholesaler, a corrupt bank employee, money laundering, patient recruiters and compromised beneficiaries. The faculty will offer an account of law enforcement’s collaboration with the NBI-MEDIC, the ZPIC, Medicare Part D plan sponsors, Pharmacy Benefit Managers and state regulatory agencies. The key points of the session will be; invoice reviews, identifying fake pharmaceutical wholesaler invoices, money laundering, and interviewing witnesses/subjects.

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

They billed what with what? Was that really necessary?
Thursday, 2:15 pm - 3:15 pm
View Description Faculty will demonstrate how revenue generating tests and procedures are often billed together in an effort to maximize revenue for the provider or facility. These codes are often not supported for billing as the documentation in the record does not support billing of the separate procedure and/or the medical necessity of the additional service or procedure is not demonstrated in the record. This session will provide specific code sets for the attendee to take back and data mine for, along with the CPC® or HCPCS® documentation criteria for the high-risk code(s). Join this session and hear a variety of examples from several specialty areas including radiology, behavioral health, chiropractic, oncology, as well as general practice.

Shauna Vistad, AHFI, CPC, CFE, CFI
Manager Provider Audit and SIU, Blue Cross Blue Shield of North Dakota

Kristine Tanory, MBA, BSDH, CPC, CFE
Senior Audit Investigator, External Audit and Investigations Department, Regency BlueCross BlueShield of Oregon

Investigating FWA in the Genetic Testing Space
Thursday, 2:15 pm - 3:15 pm
View Description During the last few years, genetic testing labs have increasingly marketed "panel tests" and patient payment limits to their ordering providers. As a result, health insurers are being inundated with claims for all different types of genetic laboratory tests – claims which are confusing and often difficult to audit. During the last few years the presenters have conducted several successful FWA investigations involving genetic testing laboratories. This session will provide examples of techniques utilized during the course of these investigations and will also provide an overview of common provider defenses.

Brian Robinson, CFE
Managing Investigator, Harvard Pilgrim Health Care

Jessica Roy, CFE, CPC-A
Investigator, Special Investigations Unit, Harvard Pilgrim Health Care

Qui Tam: The Case of Lack of Oversight of Medical Residents
Thursday, 2:15 am - 3:15 am
View Description Medicare and Medicaid will pay for radiology work done by residents but an attending physician must certify that he or she reviewed the images and agrees with the resident's report. Relator (the whistleblower) was a radiologist at the University of Missouri-Columbia hospital. He filed a qui tam (False Claims Act / FCA case), alleging that attending radiologists were certifying residents' reports without viewing the images. This raised obvious patient harm concerns and indicates that Medicare/Medicaid may have paid for claims it should not have paid. Attendees will learn about the Supreme Court's "arm of the state" analysis in the context of an FCA settlement, as well as investigation tips that can be leveraged in trial.

Cindi Woolery
Assistant United States Attorney, United States Attorney's Office

Fran Borin
General Investigator, U.S. Dept. of Health & Human Services Office of Inspector General

Jennifer Constine
Special Agent, Defense Criminal Investigative Service

Is Your Organization Overstating Payment Integrity Savings?
Thursday, 2:15 pm - 3:15 pm
View Description Investigators have multiple tools at their disposal to address payment vulnerabilities, but which tools are likely to achieve the desired provider change in behavior? The most common methods of measuring payment integrity savings often overstate savings, leading to a risk of spending more on certain initiatives than what is saved. Also, common methods don't put the various potential tools on a level playing field, making it difficult to compare different options. This session will provide example savings methodologies, cover specific examples from the methodologies used by CMS, and provide suggestions for how these methodologies can be adapted to other situations.

Marin Gemmill-Toyama, PhD
Director, Division of Outcomes Measurement, Centers for Medicare and Medicaid Services

Building the Ideal National Medicaid Dental Anti-Fraud, Waste and Abuse Program
Thursday, 2:15 pm - 3:15 pm
View Description The development and creation of effective anti-fraud, waste, and abuse (FWA) program is a critical component to ensuring that the shift towards value-based health care is successful. To build an effective program and ensure its long-term success, it is important to develop strong internal and external stakeholder relationships to implement best practices and deliver strong cost savings for clients. The faculty in this session will offer their insights into how an SIU can promote program integrity and compliance strategies across multiple internal and external partners and create a comprehensive utilization review and utilization management program that combines and complements prevention and investigation activities. Faculty will also explain how to apply a diverse range of claims processing controls, algorithms, and edits that factor in investigation results so that up front protections can be continually reinforced.

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

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

James Thommes, MD

Combining Analytics and the Cloud to Detect Fraud in Real-Time
Presented by CGI, an NHCAA Platinum Supporting Member

Thursday, 2:15 pm - 3:15 pm
View Description Advanced technology is creating powerful new opportunities to identify and prevent fraud, waste and abuse (FWA) in near real-time and realize dramatic results. This session will explore how to harness data analytics and secure cloud capabilities to improve both the speed and accuracy of FWA detection, both prepayment and post payment. We will discuss how to empower your audit team with sharper, data-driven insights, as well as proven ways to transform your end-to-end FWA process. Join us.

Robert Rolf
Vice President Global Fraud Strategy, CGI

Hector Rodriguez
Worldwide Health Chief Information Security Officer, Microsoft

Fraud Trends, Data Analysis and Investigative Techniques in the Investigation
of Home Health Fraud

Thursday, 3:30 pm - 4:30 pm
View Description This session will focus on successful investigative techniques used in home health care fraud investigations in Chicago, as well as an overview of the fraud schemes and how they have evolved over the years. Attendees will gain a greater understanding of complex home health fraud schemes involving physicians, nurses, marketers and home health company owners/operators. Faculty will offer best practices commonly used in investigations by the Medicare Fraud Strike Force focusing on home health investigations and prosecutions.

Mario Pinto
Assistant Special Agent in Charge, U.S. Dept. of Health & Human Services, Office of Inspector General

Jeffrey Jamrosz
Supervisory Special Agent, U.S. Dept. of Justice, Federal Bureau of Investigation

Building your Presentation Skills: Tips, Tricks and Best Practices
Thursday, 3:30 pm - 4:30 pm
View Description This session focuses on tips and tricks for dynamic presentations and public speaking engagements. Whether a new investigator or experienced senior manager – this session will help the attendee master critical speaking skills complemented by effective MS Powerpoint presentations. This session will also cover presentations most commonly utilized by anti-fraud personnel including case presentations to attorneys, and large audience engagements for investigative partners. Learn techniques utilized by successful speakers, and transform your own speaking style to become a persuasive and effective communicator.

Jennifer Trussell
Chief Investigator, Office of Counsel to the Inspector General, U.S. Department of Health & Human Services, Office of Inspector General

Mobile Diagnostic Testing: Understanding the Red Flags in IDTF Schemes
Thursday, 3:30 pm - 4:30 pm
View Description Overview of Medicare reimbursement and regulations on independent diagnostic testing facility (IDTF). Attendees will hear about case example involving Nita and Kirtish Patel, the owners of Biosoind Medical Services, and their circumvention of policies and requirements to have licensed medical professionals read and interpret IDTF services. The faculty will offer insight on what IDTF is and who is required to legally operate under Medicare. Real world examples will provide perspective on what to look for in IDTF cases.

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

Medical Policy Challenges: The Impact of Rapid Cross-Divisional Policy Development and Modification to Address Fraud Prevention
Thursday, 3:30 pm - 4:30 pm
View Description In an environment with ever increasing challenges for payers, this session will provide an overview of a cross-divisional model which establishes strategies that improve member outcomes, reduce friction points for providers and ultimately drive value to the healthcare organization. Presenters will discuss leveraging clinical and business acumen to identify opportunities that 1) reevaluate longstanding practices to prevent "leakage" and 2) keep pace with advances in routine and diagnostic healthcare delivery and the related billing uncertainty, uncertainty that -- if left unchecked -- can lead to excessive reimbursement and the depletion of resources available for provision of benefits that improve the of quality of care.

Jennifer Billings, PharmD, BCGP
Clinical Advisor, National Medicare Clinical Review Expertise Team, Humana

Gregg Bingham, JD
Process Manager, Claim Payment Policy and Compliance, Claims Process Organization (CPO), CPO Solutions, Humana



Ethics Seminar
Friday, 9:30 am - 11:30 am
View Description 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 course is designed to meet the American Certified Fraud Examiner CFE ethics training requirement.

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

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

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

Combating a New Era of Foreign Claim Fraud and Abuse
Friday, 9:30 am - 11:30 am
View Description Foreign claim fraud and abuse may be a familiar issue, but the tactics employed by its perpetrators are always evolving. Today's schemes involve foreign providers billing insurance carriers via American billing agencies, and insurance beneficiaries are threatened with Collections should the insurer not pay the claim as billed. Faculty will share emerging foreign claim developments and inform attendees of the elements of a robust foreign claim program, including a foreign claim review check-list. In addition to walking attendees through this investigative process, the faculty will delineate critical internal and external resources utilized in fraud and abuse prevention.

Shannon Cordes, MPA
Investigator III, Anthem Inc.

Fran Shirek, AHFI
Senior Investigator, Special Investigations Unit – West, Anthem Inc.

Joaquin Basauri
Senior Investigator, National Special Investigations Unit, National Compliance, Ethics & Integrity Office, Kaiser Permanente

A Focus on Pill Mills: Examining the Aggarawal and O’Brien Cases
Friday, 9:30 am - 11:30 am
View Description In this two-part workshop, attendees will learn specific investigative methods and tools used to investigate and prosecute two cases related to pill mill schemes.

O’Brien and Pagan’s Motorcycle Club Pill MillIn this first case study, faculty will present lessons learned from O’Brien and Pagan’s Motorcycle Club Pill Mill Investigation. The faculty will address how best to work with sources and informants to make consensual recordings of physicians and what evidence is typically necessary to bring charges against a physician for writing medically unnecessary prescriptions. This session will also examine data mining patient files and preparing for a large scale trial.

Diana Huffman
Special Agent, Federal Bureau of Investigation

Bryan Lacy
Special Agent, U.S. Dept. of Justice, Federal Bureau of Investigation

Working a Cold Case: US vs. Shelinder AggarwalThe second case study will dive into the details of a pain management physician whose medical license was suspended by the Alabama Board of Medical Examiners (ALBME). This session will show how the FBI pursued a renewed case against Aggarwal in 2015, utilizing the investigation of the ALBME, audits and documentation of the Medicare ZPIC and benefit integrity representatives, as well as an NHCAA RIA . This session will also highlight the challenges of charging a medical necessity case, pursuing diversion resulting in death charges, and seizing assets. The faculty will offer insights on how to identify health care fraud in a pill mill case and recoup insurance overpayments.

Susan E. Shimpeno
Special Agent, U.S. Dept. of Justice, Federal Bureau of Investigation

Chinelo Dike-Minor
Assistant United States Attorney, Northern District of Alabama