Course Description:

More than $2.2 trillion is spent on healthcare each year in the US. Unfortunately, a large and growing portion of that total is lost to fraud, waste and abuse (FWA).

Though the healthcare legal status quo is undergoing change, experts express doubt that insurers, government agencies, private medical practices and—most of all, patients—will be any less vulnerable to FWA in coming years.

This two day in-person seminar will provide attendees with a strong foundation of practical knowledge about how common frauds are committed using a combination of lecture, exercise and group breakout sessions. In addition, the important topic of Ethics as a tool for deterring fraud in all industries will be addressed in practical terms in Day 2 of this event.

Learning Objectives:

  • Understanding the HC fraud and ethics problem
  • Identify the red flags of FWA
  • How to detect and investigate FWA
  • Building an anti-fraud control environment

Course Objectives:

Key goals of the conference will include learning:

  • Common and uncommon healthcare fraud (HC) schemes threatening organizations today
  • Who commits HC fraud
  • How to detect the red flags of common HC schemes
  • Essential fraud detection tools and techniques
  • Software tools for auditing for HC fraud
  • Best practices for developing and implementing anti-fraud controls

Who will Benefit:

  • Internal and external audit professionals
  • Internal control professionals
  • Finance and accounting management
  • Compliance/ regulatory professionals
  • Security professionals
  • Fraud examiners
  • Procurement/purchasing and Payables Specialists
  • Senior Managers
  • Benefit plan administrators
  • Healthcare institution managers

Course Outline:

Day One (8:30 AM – 4:30 PM) Day Two (8:30 AM – 4:00 PM)

Registration Process: 8.30 AM – 9.00 AM

Session Start Time: 9.00 AM


Part 1: Introduction

  1. Statistical perspective: Some shocking data about healthcare fraud
  2. Who commits fraud -- The Fraud Triangle (Graphic scenario of presence of all three components)
  3. Lessons from healthcare Fraudsters: (Examples of real-life frauds that can and do affect large not-for-profits (NFP)

Part 2: Common Types of Healthcare Fraud

  1. Billing for services that were never rendered-either by using genuine patient information, sometimes obtained through identity theft, to fabricate entire claims or by padding claims with charges for procedures or services that did not take place.
  2. Billing for more expensive services or procedures than were actually provided or performed, commonly known as "upcoding"-i.e., falsely billing for a higher-priced treatment than was actually provided (which often requires the accompanying "inflation" of the patient's diagnosis code to a more serious condition consistent with the false procedure code).
  3. Performing medically unnecessary services solely for the purpose of generating insurance payments-seen very often in nerve-conduction and other diagnostic-testing schemes.
  4. Misrepresenting non-covered treatments as medically necessary covered treatments for purposes of obtaining insurance payments-widely seen in cosmetic-surgery schemes, in which non-covered cosmetic procedures such as "nose jobs" are billed to patients' insurers as deviated-septum repairs.
  5. alsifying a patient's diagnosis to justify tests, surgeries or other procedures that aren't medically necessary.
  6. Unbundling - billing each step of a procedure as if it were a separate procedure.
  7. Billing a patient more than the co-pay amount for services that were prepaid or paid in full by the benefit plan under the terms of a managed care contract.
  8. Accepting kickbacks for patient referrals
  9. Pharmaceutical frauds—bribery, kickbacks, falsifying clinical documentation/research
  10. DME frauds

Other Frauds Threatening Healthcare and other Organizations:

  1. Vendor fraud (Case studies that show new ways vendor fraud can be committed)
  2. Check fraud (illustrations of forged/altered checks)
  3. The growing threat of cyber-crime (hacking/information theft, system sabotage, viruses, etc)
  4. Social engineering (Phishing, pretexting, smishing, spear phishing)
  5. Embezzlement (General definition; 2-3 case studies)
  6. T&E fraud/Misuse of company credit card or P-card
  7. Collusion w/ domestic or international vendors (kickbacks, bribery)
  8. Identity fraud (Graphic description of ways internal ID theft/fraud is committed pretexting, using patient’s credentials to commit fraud, theft of patient ID)
  9. Theft/falsification of confidential information (medical record falsification, employee data, etc.)
  10. Theft of assets (laptops, physical equipment, software piracy)
  11. Payroll Fraud (Manipulating payroll systems; ghost employees)
  12. Procure-to-Pay fraud (Procurement — Receiving—Accounts Payable Cycle)
  13. Financial reporting fraud (HealthSouth)


Part 3: Conducting a Fraud Risk Assessment and Recognizing the Red Flags of Internal Fraud

  1. Fraud Risk Mitigation Cycle - Implementing a Company-Wide System for Detecting, Preventing and Investigating Fraud
  2. Steps to Conducting a Successful Fraud Risk Assessment
  3. Embezzlement red flags (Behavioral changes, accounting anomalies)
  4. Cash theft red flags (anomalies in daily reconciliations, check-for-cash indicators, etc)
  5. T&E fraud red flags (Unusually high expense claims; photocopies of receipts, etc) frequent switches in vendors; vendor address is a P.O. box)
  6. Collusion/kickback/bribery red flags (long-time vendor suddenly replaced, pricing anomalies, etc)
  7. Identity fraud red flags (internal) (Employees complain of ID theft problems, customer complaints)
  8. Theft of confidential information (Example: Scientific fraud/fraudulent scientific research)
  9. Theft of assets/industrial equipment (laptops, software piracy, construction materials, equipment, gasoline, confidential/proprietary information)
  10. Payroll fraud (terminated employees still receiving checks; payroll amounts fluctuate)
  11. P2P fraud red flags (Suddenly higher costs of supplies or services; low quality of delivered merchandise)
  12. Financial reporting fraud (Unusually high revenues, odd patterns in receivables, etc)
  13. Counterfeiting and piracy (Graphic samples of red flags)
  14. Internet/cyber-fraud

Part 4: Fraud Detection/Audit Techniques

  1. Data analytical healthcare fraud detection applications…
  2. How to find anomalies of external frauds such as excessive billing amounts, higher per-patient costs, excessive per-doctor patients, higher per-patient tests. This excess can be identified using data analytical tools. Provider statistics include;

    1. Total amount billed.
    2. Total number of patients.
    3. Total number of patient visits.
    4. Per-patient average billing amounts.
    5. Per-patient average visit numbers.
    6. Per-patient average medical tests.
    7. Per-patient average medical test costs.
    8. Per-patient average prescription ratios (of specially monitored drugs).
  3. Internal fraud detection procedures:
    1. Monitor Employee Email, other activities
    2. Surprise Internal Audit
    3. Regular internal audits, incorporating fraud audit testing and data analysis
    4. Ratio analysis
    5. Physical inspection of inventory
    6. Manual review of all vendors (to ensure absence of sham vendors)
    7. Data-analysis of vendor master file, pricing patterns, inventory patterns, etc.
    8. Manual review/assessment of payroll sample data (to ensure absence of ghosts)

Examples of Fraud-Audit Measures at Work

    • Accounts Payable Fraud Auditing (List of fraud-audit/detection measures)
    • Payroll Fraud Auditing (List of fraud-audit/detection measures)

Whistleblower hotlines: How to set them up and manage them (detailed discussion of do’s and don’ts). Detailed instruction on best practice.

Part 5: Investigation Techniques

  1. Forensic Accounting Investigation—What it Is
    1. Different from Internal Audit/ When to Call in Forensic Accountant/Auditor/CFE
    2. Forensic accounting/auditing techniques: Data Mining and Analytics (most powerful forensic accounting investigative tool); ratio analysis;
    3. Gathering evidence – Document retention, chain of custody, preservation, mistakes to avoid
    4. Securing crime scene
    5. Interviewing/interrogating suspects – Detailed steps with examples
    6. Documenting findings


Part 6: Internal Controls and Other Fraud Prevention Measures:

  1. Who Should Manage Anti Fraud Activities
  2. Internal Controls: Do’s and Don’t’s
  3. Best Practices in Anti-Fraud Controls.
    • General controls: Segregation of Duties, Delegation of Authority, Background investigation
    • Specific operations-level controls for each fraud category.


Part 7: Ethics vs. Fraud: Important Distinction

  1. Policy differences
  2. Ethical standards/Tone at the Top
  3. Enforcing ethical standards
  4. Ethical dilemmas: Group exercise
  5. An ethics and compliance oversight committee comprised of City of Dallas department representatives
  6. An ethics and compliance office
  7. An ethics hotline for all employees for reporting any kind of ethics issue
  8. An organizational ombuds office
  9. A revised Code of Ethics and other ethics-related policies
  10. Online training programs on ethics policies
  11. A program for senior managers on fraud prevention
  12. A program for senior managers on ethical leadership

Meet Your Instructor

Peter Goldmann
MSc, CFE, Owner, White-Collar Crime 101 LLC

Peter Goldman has 25 years of experience as a business journalist and trainer, having launched, edited and published numerous business trade periodicals covering small business, international trade, management strategy, banking and personal finance. Mr. Goldman is a Certified Fraud Examiner (CFE) and a member of the Editorial Advisory Committee of the Association of Certified Fraud Examiners (ACFE) as well as an active member of the Institute of Internal Auditors, the High-Tech Crime Investigation Association and the IOFM Controller Certification Advisory Board. He is a regular columnist for the ACFE’s newsletter, The Fraud Examiner and is a frequent contributor to other leading industry publications on anti-fraud topics. He has appeared on Fox Business News, The Wall Street Journal This Morning, The New York Times and Internal Auditor magazine.

He is president of White-Collar Crime 101 LLC, the publisher of White-Collar Crime Fighter, a widely read monthly newsletter for internal auditors, controllers, corporate counsel, financial operations managers and fraud investigators. He is the author of Fraud in the Markets: Why it Happens and How to Fight It, published by John Wiley & Sons, as well as four other anti-fraud books. He also developed FraudAware, a leading fraud awareness training program.

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Written cancellations through fax or email (from the person who has registered for this conference) received at least 10 calendar days prior to the start date of the event will receive a refund — less a $150 administration fee. No cancellations will be accepted — nor refunds issued — within 10 calendar days from the start date of the event.

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Location :

Special Offer for the attendees of this seminar:

Rooms available at only USD 239 per night.

Call hotel and give the reference “ComplianceOnline group”

Hotel rooms are limited and based on availability

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How to Reach

Driving Directions from Nearest Airports:

Reagan National Airport – DCA: Hotel direction: 6.6 mile(s) SW
  • Take US-1 ramp right (north) toward I-395 N/Washington/I-66 West
  • Turn right onto US-1 North
  • Merge onto I-395 N toward Washington
  • Turn right onto New York Ave NW/US-50
  • Turn right onto Florida Ave NE
  • Turn right on 2nd Street NE.

Washington Dulles International Airport – IAD: Hotel direction: 29 mile(s) W
  • Take Dulles Airport access road East toward Washington
  • Take exit VA 267 East
  • Exit onto I-495 toward Baltimore/Bethesda MD
  • Take exit #43 onto George Washington Memorial Parkway /Washington
  • Take ramp onto I-395 N toward Washington
  • Turn right on New York Ave NW
  • Turn right on Florida Ave
  • Turn right on 2nd street NE.

Baltimore/Washington International Thurgood Marshall Airport – BWI: Hotel direction: 30 mile(s) N
  • Exit I-195 West
  • Exit #2B onto MD-295 South
  • Exit US - 50 West
  • Take a left on 1st Street NE
  • Take a left on N street NE
  • Drive around the bend.

Other Transportation:

Bus Station
  • Greyhound Bus Terminal: 0.3 mile(s) S

Subway Station
  • NoMa-Gallaudet U (New York Ave) - Red line: 0.1 mile(s) E

Train Station
  • Union Station: 0.5 mile(s) SW

Disclaimer: Directions to the venue above have been taken from the hotel website. Attendees are advised to check with the hotel for confirmation of these directions before starting for the venue. ComplianceOnline is not responsible for any inaccuracies in the same.

Media Partners


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  • Announcement article of the conference on the Magazine and/or Website.
  • Dedicated email blast to all subscribers of Media Partner.
  • Article on the Magazine and/or Website after the conference.

Local Attractions

Explore a quaint historic town just over the Potomac River from Washington, DC. The lively waterfront area has plenty of things to do. Visit colonial houses, public parks, churches, museums, a marina, unique shops, and restaurants.

The Washington DC region is lucky to have this wonderful historic park that offers a quick relief from hectic city life. Take the whole family for a walk and learn about the historic C & O Canal, explore the region's bike trails or spend a few hours kayaking and enjoying the breathtaking scenery.

Take a picnic and enjoy spectacular views of the Potomac River at this 800 acre park, located just 14 miles from Washington DC. Great Falls offers a variety of activities including hiking, kayaking, rock climbing, bicycling, and horseback riding.

Georgetown is the capital’s historic waterfront that today is bustling with activity. The area is a shopper’s paradise and the streets are lined with restaurants of every nationality. Take a tour of historic sites, do some shopping and enjoy a meal at a local restaurant.

Explore the U.S. Capitol Building, the White House and the U.S. Supreme Court and you will gain a fuller understanding of the division of power within our democratic government. Plan ahead and note that some tours must be scheduled in advance through your Congressional Representative.

Live theatrical productions at the John F. Kennedy Center for Performing Arts are entertainment at its finest. Purchase tickets in advance for performances ranging from musicals to concerts by the National Symphony or see a free show at the Millennium Stage.

With the recent addition of the new museum and education center, Mount Vernon is now a full day excursion. Explore the state of the art galleries and theaters, visit the 500-acre estate of George Washington and his family, tour the 14-room mansion that is beautifully restored and furnished with original objects dating back to the 1740's. Be sure to plan enough time to tour the outbuildings, including the kitchen, slave quarters, smokehouse, coach house and stables. The estate is located in Northern Virginia, just minutes from Washington, DC.

Our national monuments are truly spectacular. The best time to see them is at night when they are illuminated, less crowded and parking is easier. During daytime visits, take a tour bus. Listen to informative park ranger talks and you won’t have to negotiate congested city traffic.

Start at the Smithsonian Institution Building where you can pick up a map and information on all of the museums. These national treasures cover a wide range of subjects from art to space exploration. Plan to explore those you are most interested in, but don’t try to see everything at once. Be sure to save time to see an IMAX movie at the Natural History Museum or the National Air and Space Museum.

Listen to all types of music at this national park dedicated to the performing arts. Outdoor concerts are featured in the summer and indoor performances are held the rest of the year. The park is located in Vienna, Virginia, just 20 minutes from Washington, DC.

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