ATC Tracks

Below are priority areas by track that were identified by the ATC Committee at their January meeting.

Clinical Issues for the Healthcare Fraud Investigator

  • Genetic Testing Androgen deficiency
  • Testosterone therapy
  • Cookie cutter diagnostic testing (electro dx, ultrasound, NCS)
  • Rheumatology
  • Understanding Scope of practice (Behavioral, allied health, pharmacist)
  • Allergy - self injectables, serum prep
  • DME - ventilators/glucose tolerance/diabetic pumps, wound supplies,
  • SNF
  • CT - Cardiology - Stents
  • GI Bypass
  • CPT coding schemes
  • Orthopedic devices (provider/facility/device)

Behavioral Health Fraud Schemes

  • Community Mental Health
  • Autism - schools and facilities/state mandates
  • Urine Drug Screens
  • Sober Living Facilities
  • Licensure and scope of practice
  • Diagnosis and screening tests (norms and times)
  • Frequency & levels of care
  • Facilities
  • Standards and quality of care
  • Group therapy
  • Regulation/Compliance (Parity/Baker Act, ACA, habilitation/rehab, access to records)
  • Group therapy

Detecting and Investigating Dental Fraud

  • Dental Director Panel
  • DME expenses submitted by dental (like sleep appliances)
  • Dental care submitted as medical
  • Crosswalk CDT-CPT - cloaked services
  • Dental emergency/ER/foreign
  • Emerging Trends
  • Case Studies

Fraud in the Medicaid Program

  • Genetic Testing
  • Allergy Testing
  • Home health
  • Enrollment Fraud
  • Using Medicare Regulations in the Medicaid world
  • Lock in Programs
  • Newly eligible populations - Medicaid expansions
  • Managed care audits and investigations
  • UDS
  • Facilities

Fraud Schemes and Investigative Skills

  • Schemes: Patient Harm
  • Schemes: Home health
  • Schemes: Ambulance
  • Schemes: Laboratory Services
  • Schemes: Facility Fraud
  • Schemes: NCCI, coding pair schemes, new modifier 59 extenders
  • Schemes: Multidisciplinary practices
  • Schemes: Opticians
  • Schemes: Observation Units
  • Schemes: Foreign Schemes
  • Schemes: Part C investigations
  • Schemes: Auditing behavioral health providers
  • Schemes: ID theft
  • Skills: Data analytics - using effectively
  • Skills: Detecting deception
  • Skills: Preparing cases for jury appeals
  • Skills: Electronic evidence
  • Skills: Prepayment record review
  • Skills: Medical records for specialties
  • Skills: Interviewing
  • Skills: Handling hotline calls/referrals

Pharmacy & Part D Fraud

  • High cost specialty or orphan drugs
  • Intersection of Hospice and Part D
  • Part D Panel - challenges (MEDIC, PBM, Privates, DOJ)
  • Major Providers/Pharma Case
  • Diversion
  • Off label marketing
  • Compounding
  • Counterfeit drugs/Internet Pharmacies
  • Emerging drugs
  • Steroids/HGH/testosterone
  • Institutional (SNFS)
  • Facility Billing (injectables)
  • Transmucosal Immediate release therapy

Legal, Management & Compliance Issues

  • Working with law enforcement
  • SIU structure
  • Top regulations/law impacting industry
  • OPM regs
  • Compliance requirements government and private
  • CMS, DOJ, updates
  • Case law impacting HCF investigations
  • Adverse benefit determination

Transformation of Health Care

  • ACA (potential vulnerabilities, web-eligibility, member shifting/cyber, HER, Identity Theft)
  • Value-Based Purchasing (VBP) Program
  • Rewards Programs - physician contracts with incentives for quality/efficiency
  • Medicaid Expansion issues
  • Health care Utilization (necessity)
  • Functional/integrated models
  • Personalized medicine
  • Payment Models (see # 2 and 3)
  • ACOs
  • ICD-10
  • Medical Tourism
  • Adapting Data mining to new models
  • Aligning policy to support SIU

Disability, Worker's Compensation & Supplemental Products

  • Application Fraud
  • Broker/Agent Fraud
  • Social Media/Surveillance
  • Collusion - Claimant/Provider/Runner/Agent
  • Mock interviewing of claimants
  • Overlap of supplemental and health care fraud