Detecting Healthcare Contractual Fraud, Waste, Abuse and Non-compliance - Detection, Auditing, and Oversight

Why Should You Attend:

This managed care compliance and risk analysis webinar will discuss the often overlooked but serious risk areas in the oversight of managed care contracting, network development, provider relations, business development and marketing. Within the webinar, key risk areas, methodologies for detection and investigation, and for ongoing oversight and auditing will be presented. This webinar will start from reviewing the various Provider and Payor and vendor methodologies and models, process flows, and risk areas that can and do exist. We will then review how the various models will lead to what kinds of fraud, waste or abuse. We will then discuss detection methods and processes for detection and investigation.

Finally, proactive audit and prevention tools will be discussed and presented to allow the finance and or compliance executive to prevent such issues or to detect them early in the contracting cycle.

Areas Covered in the Webinar:

• Types of Fraud, Abuse, Waste, and Non-Compliance, potentially present in managed healthcare organizations
• Typical processes and risk elements in healthcare contracting and how various models may encourage or discourage or prevent fraud, waste or abuse
• How to conduct various levels of contractual and network risk analysis to detect fraud, waste or abuse
• Various types of Managed Care Health Plan, Provider Contracts and Methodologies.
• CMS Contractual Standards
• Elements of a Contracting Oversight Audit and or Risk Analysis will be explained
• Real World examples of malfeasance and contracting fraud and abuse within managed care and related marketing will be presented
• Typical policy considerations for preventing fraud, waste, abuse in contracting and network development areas
• We will discuss how to use Risk Analysis to deal with difficult compliance issues, such as conflicts of interest
• Tools to be used for policy management and documentation will be presented
• How to adopt policies, train on them, and conduct drills on them will be discussed

Who will Benefit:

This webinar will provide valuable assistance to HMOs, Medical Groups, IPAs, MSOs, ACOs, Governmental Organizations, Insurers, hospitals, academic medical centers, and medical offices, practice groups, hospitals, academic medical centers, insurers and business associates (shredding, data storage, systems vendors, billing services, etc). The following personnel will benefit:

• Compliance director
• Chief Executive Officer (CEO)
• Chief Financial Officer (CFO)
• Chief Operating Officer (COO)
• VP, EVP, SVP of Network Development or Contracting
• FWA Investigators
• Internal Auditors
• External Auditors
• Privacy Officer
• Security Officer
• Information Systems Manager
• HIPAA Officer
• Chief Information Officer
• Health Information Manager
• Healthcare Counsel/lawyer
• Office Manager
• Contracts Manager

Instructor Profile:

Jeffrey Baron, MBA, CCEP, CHC, is Principal , Healthcare and Management Consulting at Strategic Healthcare Associates -Baron Global Ventures, LTD.

Compliance, Special Investigations, and Organization Risk Analyses and Gap Analyses: 19+ years of developing, revising, and or effectuating health plan compliance programs, overcoming regulatory challenges, development or renewal of special investigations & antifraud-waste-abuse program units, as well as implementing new legislation or programs.

Healthcare Leadership & Management: 15+ years experience managing provider and network development, contracting, compliance & operations, auditing, and providing leadership for healthcare organizations and facilities, including Healthcare Plans, Health Maintenance Organizations (HMOs), including Medicare Advantage, Medicaid / Medi-Cal, and commercial lines of business, IPAs, and PHOs.

Developed Compliance training programs, and communications to implement new laws and initiatives, for risk management reduction, or for corrective action. Including:

• HMO internal and delegated provider network statutory training programs for compliance and network development purposes, while increasing attendance by 250%, and reducing overall costs by 300%. Program Developer and organizer for health-plan
• Producer of regional Provider Compliance and Anti-Fraud –Waste –Abuse Training Seminar and Workshop
• Network Development, Contracting, Strategic Development, and Provider Relations:

Healthcare Organizational Change & Transformation:

• Medicare Part D Medicare Advantage implementation task-force that created new Medicare Part D program.
• Consultation to governments, investment banking firms, which included privatization, health system development & regulatory develop of system structuring for new healthcare laws and regulations.

Topic Background:

At times of ambient economic stress and uncertainty and change in healthcare, some providers, contractors, and internal contracting or network development staff (or management) increasingly may succumb to temptation to divert funds to themselves, relatives, or providers offering bribes or incentives to them personally. They may seek unfair, or illicit compensation, kickbacks, favorable treatment for giving out favorable contracts, or even for moving enrollees from one provider to another (i.e. Medicaid). As CMS and external auditors continuously hone down, the risks of not overseeing this keep determinant of medical costs and organizational profitability cannot be ignored. At a time of Qui Tam lawsuits and disgruntled employees or providers or vendors, every Compliance, Finance, or even Contracting or Network Development Managers , owe it to themselves to arm themselves with knowledge and tools to better detect , prevent, and respond to issues in their networks.

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