This course may be delivered on-site, at your location, or streamed live via the internet

Healthcare fraud schemes can range from simple to very complex. Understanding the steps of an investigation and available resources is only the first step. Doing your job efficiently is just as important as doing it effectively. We will teach you everything from effective documentation management and maintenance to the best practices when interviewing. Most importantly we provide you with an extensive coding overview that covers CPT codes and CMS policies to help you understand coding and billing as an investigator. This course is based upon a methodology that uses the OIG “Best Practices” for healthcare fraud investigations.  Advize’s cadre of retired OIG Special Agents, who are specifically and uniquely trained in the above areas, provide SIU analysts and investigators with up dated skills to make conducting healthcare fraud investigations produce more outcomes.

Training can be customized to include part or all of the topics above, as well as other areas needed to ensure that the entire SIU team is working in a consistent manner.  Investigations can often lead to administrative hearings, and/or criminal and civil proceedings.  OIG agents working with Advize have years of experience in all of these areas, as well as having been involved in numerous trials.  Advize’s differentiators are our ability to provide real life case examples that were worked by our retired OIG agents, and bring that real life experience into the training environment.  Our professionally trained instruction staff work to facilitate a bottom up review of all aspects of your SIU team, from reviews of FWA polices to SIU operational procedures.

Whether you are an experienced investigator or are just getting started in the field, this course will give you the skills you need to manage a case. SIU teams traditionally have investigators with widely varying levels of experience. Having a training course that brings all of the investigative team in one place, facilitates a “level set” so there is consistency across all levels of experience.

Investigators are needed in every kind of healthcare fraud, waste and abuse environment, including insurance companies and anywhere claims are paid.

The training program covers not only the topics noted above, but focuses on the completion of the investigation, through any administrative or court proceedings. Many investigators are well equipped to conduct an investigation, but are not prepared to explain and present their findings and evidence to the prosecuting body. Our training program will facilitate an understanding of evidence collection, documenting case files, documenting interviews and external/internal contacts and the legal process once your investigative findings leave the SIU. Complete with practice examples, 23 engaging lectures, helpful chapter quizzes, and detailed instruction by a certified medical coder, this course prepares you for on the job coding and for ICD-10-CM coding proficiency exams.

Who this course is for

  • Medical coders who are involved in FWA cases
  • New SIU hires and experienced SIU investigators where management is seeking to have uniform methods of conducting investigations
  • Beginners who want to learn how to analyze claims for FWA
  • People who want to break into the field of medical investigations

Author & Instructor

eric-rubenstein-siu-oig

Mr. Rubenstein is a retired federal law enforcement officer with over 25 years of experience in white-collar crime investigations. His wide-ranging experiences involving federal healthcare programs such as Medicare and Medicaid have demonstrated great success in complex criminal case management, planning, and convictions. Having been involved in cases resulting in over $500 million in restitution, forfeiture, damages, penalties, and fines and over 150 convictions involving healthcare fraud – Mr. Rubenstein is dedicated to the identification and prevention of fraud, waste, and abuse in the healthcare space.

Course Curriculum

Investigative Planning

  • Receipt of complaints (reactive process)
  • Vetting complaints
  • Calculating loss amounts
  • Reviewing policies
  • Identifying potential statutes that were violated
  • Gathering intelligence and information relative to the provider

Case/Investigative Management

  • Initial data analysis
  • Opening/Case Initiation
  • Sources of Information for investigators
    • Public databases
    • Proprietary databases
  • Investigative file documentation
  • Referring investigations to law enforcement

Interviewing and Interrogations (differences and limitations)

  • Types of interviews
  • Interview preparation
  • Documenting interviews
    • Audio
    • Video
    • Handwritten/typed notes
  • Documentation maintenance
  • Field/office interviews
  • Overall observations when speaking to people (not necessarily interview related, but for the purpose ensuring proper documenting of events)

Onsite Visits

  • Record collection
  • Photographs
  • Site identification/labeling
  • Evidence collection

Data Analytics

  • Importance of data in the investigative lifecycle
  • Examples of how data driven investigations can be productive/Healthcare Strikeforce related model
  • Demonstration of some simple Excel analytics that can be done from your desk
  • Impossible day (is it really)
  • Matching multiple data sets (provider/in patient, HHA, DME)
    • Understanding relationships between providers, patients
    • Geolocating