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Anti-Fraud Training and Accreditation

Anti-Fraud Training and Accreditation. Erin Carlson Sr. Director, Education & Training National Health Care Anti-Fraud Association. Today’s Presentation. The Importance of USING Education to Combat Fraud. Education is the most powerful weapon which you can use to change the world.

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Anti-Fraud Training and Accreditation

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  1. Anti-Fraud Training and Accreditation Erin Carlson Sr. Director, Education & Training National Health Care Anti-Fraud Association

  2. Today’s Presentation

  3. The Importance of USING Education to Combat Fraud

  4. Education is the most powerful weapon which you can use to change the world. - Nelson Mandela

  5. Medical Student Education A Roadmap for New Physicians • Adding anti-fraud training to medical school curriculums • Exposure to ethical challenges in business practices • Explanation of the health care anti-fraud regulations and impact on their livelihood if violated • http://oig.hhs.gov/compliance/physician-education/index.asp Prsenter Logo Here

  6. Anti-Fraud Compliance Training • health care fraud and abuse laws • basics of health care compliance programs • what to do when a compliance issue occurs Prsenter Logo Here

  7. Whistleblower Protection • How to report fraud • Protection when reporting fraud • Consequences of not reporting Prsenter Logo Here

  8. Consumers Training Consumers Senior Medicare Patrols Education goals • Safeguard benefits • Help recognizing and reporting fraud • Assistance reporting fraud StopMedicareFraud.gov

  9. State Anti-Fraud Training Requirements • Training requirements for SIU staff • 50% of states require • Average annual requirement 18 hours Prsenter Logo Here

  10. NHCAA’s E&T Strategy

  11. About NHCAA To protect and serve the public interest by increasing awareness and improving the detection, investigation, civil and criminal prosecution and prevention of health care fraud. Prsenter Logo Here

  12. How NHCAA Achieves the Mission

  13. NHCAA’s Education & Training Programs • Annual Training Conference & Expo • NETS Programs – in-person and online • Audio Conferences • Distance Learning Opportunities • Interest Groups • Podcasts • Online Community

  14. Investigator’s Boot Camp • 4 day training for new investigators • Introduction to the steps of the investigative process • Hands on exercises • Apply learning by solving a case in groups

  15. Offering Credit for Education • CPE credit • Transcript calculator and NHCAA learning management system • Offering CPE credit to outside organizations

  16. Accreditation for Fraud Investigators

  17. The Importance of Industry Designations • Standardization • Assurance an individual can perform a job or task • Career Advancement • Competitive Advantage • Revenue Enhancement

  18. Health Care Anti-Fraud Designation Programs

  19. General Requirements • Certification exam • Grandfather clause • Training requirement • Basic education threshold • Demonstrate employment in the field • Recommendation by other designees, supervisor

  20. Accredited Health Care Fraud Investigator (AHFI) • Founded in 2002 by NHCAA • Exam Process and Experience Process until 2009 • Currently have 489 designees, add about 45 each year • Lose about 20 each year • Added an AHFI curriculum through our training in 2011 • Added a voluntary AHFI vendor program in 2013 • Added a practice exam in 2014 • In 2016 will add an SIU Leadership component

  21. Accreditation Review Board • Comprised of three members of the NHCAA Board • One is law enforcement • Review and approve applications

  22. Accreditation Committee • Volunteer members from NHCAA’s membership, with AHFI designations • Meet to create and review examination questions • Suggest new benefits, requirements and monitor the program administration

  23. AHFI Designation Program Requirements • 3 years of health care anti-fraud employment • 75 hours of anti-fraud training • Minimum of high school diploma • 3 letters of recommendation • Successful completion of a 200 question exam • 70% or 140 is a passing score • Membership status

  24. AHFI Curriculum No core materials • Health Care Fraud Handbook • Investigators Boot Camp • AHFI Prep Course • Sample Exam Content reflects “demonstrated knowledge” - drawn from what an investigator should have been exposed to, or mastered in the first 3 years of their career.

  25. AHFI Examination Content Outline I. Nature & Scope of U.S. Health Care System (10%) II. Medical/Health Insurance Terminology/Workings (15%) III. Types of Frauds and Fraud Indicators (30%) IV. Detection/Investigation Skills and Knowledge (25%) V. Legal/Statutory/Regulatory Aspects (20%)

  26. Sample Question Exculpatory evidence is evidence that 1. is a written document 2. indicates someone’s guilt 3. does not indicate anything 4. suggests a person’s innocence

  27. Sample Question The coding nomenclature for dentistry services is called: 1. Current Dental Terminology (CDT) 2. American Dental Association (ADA) 3. Dental Procedure Codes (DPC) 4. Orthodontic Coding Classification (OCC)

  28. Exam Development Process • Work with a professional exam administration organization • Identify content deficiencies, tweak the content outline • Build questions by consensus on committee calls • Contractor standardizes question formats, codes based in the outline • Exam shelf life is 2 years • Each cycle committee comes together to take a 300 question exam, to pare down to 200 to be used on the next cycle.

  29. Exam Continuous Quality Improvement Process • Exam is evaluated after each testing cycle • Committee reviews all questions which “score” 100% • Committee evaluates all questions who score under 30% • Contractor provides us with 3 years of history on each exam question as our sample audience per cycle is very small

  30. Candidates’ Exam Options and Scoring • Candidates have the option of a proctored paper or computer based exam • Offered 4 times annually (8 times in a cycle) • Candidates’ scores are measured across the 5 major content areas • Must pass with a 70% and in more than 3 content areas • Candidates can retake the exam twice in a cycle, 3 times total.

  31. AHFI Maintenance Requirements Reviewed every 3 years: • Membership status • Completion of 36 training hours (CPEs) from NHCAA • 24 training hours from other sources • Renewal fee

  32. Designee Benefits • AHFI plaque and pin • Access to complimentary training • Newsletter • Recognized on the website and at all in-person events • Online community • Networking events at the Annual Conference • Reciprocal credits with other designations and online universities

  33. Monetizing the Designation • AHFI Vendor Program • Marketing relationship • Offer AHFI Approved status

  34. THANK YOU

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