Healthcare Fraud Prevention and Detection
Learn how to detect, prevent, and respond to healthcare fraud with practical tools, real-world case studies, and actionable strategies. This course explores common fraud schemes, regulatory frameworks, and the role of CPAs in fraud mitigation using data analytics and internal controls. Ideal for accounting and finance professionals in the healthcare space.
Course Description
Healthcare fraud can have devastating impacts on patient care, financial integrity, and regulatory compliance. This intermediate-level course equips accounting and finance professionals—especially CPAs—with the knowledge and tools needed to proactively prevent, detect, and respond to fraud, waste, and abuse in healthcare organizations.
Through a comprehensive curriculum, learners will explore key fraud schemes affecting providers, payers, and patients, along with enforcement processes and applicable regulations including the False Claims Act, Anti-Kickback Statute, and HIPAA. Real-world case studies illustrate red flags and control failures, while structured frameworks such as COSO and the fraud triangle guide learners through effective risk assessments.
Participants will also gain hands-on insights into data-driven detection methods, including anomaly detection, benchmarking, and predictive modeling, as well as the importance of tone at the top and whistleblower protections.
Whether you're conducting audits, advising on compliance, or managing financial operations in the healthcare sector, this course will help you identify vulnerabilities and implement controls that reduce risk and enhance fraud oversight.
In this course, you'll learn...
Course Objectives
To recognize common types and schemes of healthcare fraud and abuse.
To understand relevant laws, regulations, and enforcement mechanisms.
To identify internal control strategies to prevent and detect fraud in a healthcare setting.
To apply data analytics / audit techniques to detect fraudulent activity.
To evaluate “real-world” case studies to understand red flags and lessons learned.
To recommend CPA-relevant best practices for monitoring and mitigating fraud risks.
How you'll apply these skills...
Detect Fraud Through Financial Patterns: Analyze claims and billing data to identify anomalies indicative of upcoding, phantom billing, or unnecessary services.
Conduct Targeted Fraud Risk Assessments: Use COSO and fraud triangle frameworks to evaluate internal vulnerabilities across departments.
Design and Evaluate Internal Controls: Implement segregation of duties, audit trails, and reconciliation processes to prevent and detect fraud.
Investigate Red Flags with Data Analytics: Apply tools like anomaly detection, benchmarking, and Benford’s Law to validate suspicious activity.
Interpret and Apply Healthcare Regulations: Assess compliance with key laws like the False Claims Act, Anti-Kickback Statute, and HIPAA.
Respond Confidently to Violations: Navigate the enforcement process and contribute to resolution through proper documentation and escalation.
Course Instructor
Michael Carroll, CPA, CISA, CISM
Michael is an accounting and information security professional. He is also an Adjunct Professor at several higher education institutions, where he is responsible for teaching various accounting and information technology courses.
Michael earned his MBA in Accounting and B.S. in Accounting / Accounting Information Systems from Canisius University. Additionally, Michael is a Certified Public Accountant (CPA) and a Certified Information Systems Security Professional (CISSP). Michael is a current member of the NYCPA’s Education Committee and has been an Advisory Board Member for the Academy of Finance (AOF) since 2020.
Michael enjoys traveling, hiking, and watching the Buffalo Bills. He has also participated in several marathon events.
Course Content
Additional Info
Format
5-20 min. videos, 2 quizzes, and a final assessment
Field of study
Auditing
CPE Credits
CPEs 3.0
Prerequisites
Foundational Healthcare Accounting & Finance Courses (Recommended)