Medicare Fraud and Abuse

Medicare Fraud and Abuse includes:
	Healthcare investigation / healthcare fraud and abuse
	Medicare fraud / Medicaid fraud / insurance fraud
	Physician billing / physician coding
	Hospital billing
	Acute care / long term care / nursing home / home health agency / HHA / dialysis / laboratory / ambulance / durable medical equipment / DME / pharmacy
	Healthcare litigation support
	Medical record reviews
Types of Services Provided
We specialize in Health Care Fraud Investigations, Defenses, and Prevention by contracting with the federal government, Health Care law firms, criminal defense firms, and accounting firms to evaluate reimbursement issues, assist in the performance of health care audits, determine billing accuracy and assist in the determination of risk factors in due diligence and defenses.  We easily handle micro-management of large volume cases.
Cases Reviewed:
	Debt collection nursing home
	Micro-management of large volume of records for off-site reviews of home health agency medical records and physician office records for medical necessity, billing accuracy and appropriateness of care.  Focus of review was on the reasonableness of care and the detection of inappropriate billing of services.  Project included identifying fraudulent issues and Medicare overpayment.  Review findings resulted in potential criminal charges against the home health agency.  Total recovery was $3 million dollars returned to the government Trust Fund – Medicare Part A.
	Medical records review and line item billing review for the determination of medical necessity, causation, preexisting, reasonableness and appropriateness of medical treatment and billing procedures for the detection of health care provider fraud, insured fraud in PIP (personal injury protection) auto insurance subrogation cases resulting in a positive outcome.
	Performance of corporate compliance reviews, focused medical reviews, medical record audits of medical facilities, physician offices, home health agencies, IV infusion companies, nursing homes and ambulance companies for the detection of health care fraud and compliance with Medicare conditions of participation.  The focus is on testing the medical bill submitted to government payers to the medical record for documentation to support the individual services billed.
	Project management and site reviews for due diligence investigation with major accounting firm for pharmacy buy out.  The project included tool development, on-site reviews, staff interviews, medical record/billing record reviews, review of policies and procedures and final report to accounting firm.
	Team coordination and project management for due diligence investigation with major accounting firm for a national health care corporation pre-purchase of (2) states regional chain of (12) skilled nursing homes.  The investigation included on-site visits, staff interviews, review of payor billings, review of medical records, policies and procedures and report to accounting firm.  Resulted in $15 million dollar savings in purchase price.
	Participated in nationwide reviews of home health agencies to assess internal compliance with governmental requirements for home health agency services.  Identified patterns of fraud and abuse by reviewing the initial agency's intake referral process, referral orders, plans of care, physician orders, physician and staff signatures, documentation procedures, home care notes and actual bills submitted for Medicare payment.
	Performed site reviews of government payer bills, medical records, internal policies, interviewed staff members and assisted with the compilation of errors, statistical extrapolation and drafting of memos of on-site findings and issues.
	Participated in the development of a defense to civil and criminal fraud charges for Medicare B billing practices of the providers of ambulance services.  Reviewed payer regulations, coding issues and performed on-site reviews of original medical and billing records.
	Participated in follow-up audits of home health agencies to determine internal compliance with procedural changes identified in prior audits.  Audits included testing for compliance with federal regulations, medical necessity and reasonableness of care provided.
Our team members have:
	Designed and managed a multi-phase review for compliance with regulatory requirements of Federally sponsored health care programs for a large provider of renal disease management and manufacturer of dialysis products as part of a corporate integrity agreement.  Assessment included reviewing key elements of a functional corporate compliance plan, policies, procedures and employee training programs, and using statistical methodology to test the accuracy of billing for in-center hemodialysis, peritoneal dialysis (Method I and Method II reimbursement), equipment, supplies and laboratory services, as well as procedures to identify credit balances.  Managed and trained team to perform reviews and performed detailed quality check.  Developed a database to manage findings of claim-to-medical record review.  Preparation included participating in face-to-face procedural negotiations with the Office of Inspector General.
	Participated in two annual compliance reviews ordered by the New York State Department of Insurance for a regional insurance company and Medicare intermediary.  Coverage issues reviewed included in -vitro fertilization, investigational/experimental procedures, medical review for timeliness and reports, utilization review for timing, documentation, staffing, analysis and staff qualifications.
	Identified a skill-set gap within a consulting firm, then developed and presented reimbursement programs.  One program encompassed Medicare Part A and Part B reimbursement presented to partners and staff.  The second, Risk Assessment in Transactional Support, focused on reimbursement for institutional pharmacies presented to the audit transaction practice and client.
	Performed numerous due diligence reviews on the behalf of a purchaser of institutional pharmacies.  Process included interviews with owners, clinical pharmacists and business office personnel.  Procedural investigation included a review of payors, physician order process, dispensing procedures, return policy, controlled substance policy and delivery procedures.  Assessment review included exposure to qui tam actions, regulatory compliance, credentialing and fraud in billing patterns of institutional pharmacies for the acquiring party, identifying reimbursement issues, utilization patterns and exposure issue.
	Contributed to a forensic record review of billing and service patterns for the defense counsel of an ambulance company in response to Federal civil and criminal fraud charges.  Identified pertinent regulatory issues, created a database to gather and manage elements of the medical record, and developed vulnerability points for defense counsel.
	Managed a transaction support project on behalf of the purchaser of an interest of skilled nursing homes, reporting to outside counsel.  Managed on-site review teams performing due diligence of business office billing practices, review of supporting medical record documentation and licensure.  Identified risk areas in documentation of Medicare beneficiaries, certification procedures for skilled care and physician contracts. Performed follow-up visits to polemic sites.  Quantified an estimation of impact on the value of the acquisition target and exposure to government recovery steps. Resulted in a purchase price adjustment of $15 million.
	Managed numerous site reviews as part of a corporate integrity agreement for a large provider of home health services.  Project included testing claims submitted to government payors for accuracy using a probe sample and statistical sampling for overpayment estimation, detailed quality review and preliminary report generation with supporting documentation.
	Coordinated a team to perform data mining of the electronic billing records of a cardio-thoracic surgery practice to reconstruct billing patterns for outside counsel in response to an FBI investigation.  Created graphic comparisons of practice patterns of selected procedure codes with regional and national statistics.
	Coordinated an investigation project for outside counsel of a radiation-oncology practice associated with a major teaching center using statisticians, clinical reviewers and database technicians.  Determined a statistically valid extrapolation of repayment positions for counsel to negotiate with the fiscal intermediaries.
	Performed a review of a physician’s office coding and billing patterns for compliance with federal payor regulations for counsel.  Identified statistical sampling and accuracy errors found in the government’s charges resulting in a significantly lower settlement.
	Completed a multi-phased review of an integrated health care system for compliance with Federal payor regulations, including acute care centers, long term care facilities and home health agencies for outside counsel.
	Participated in a review of a leading provider of dialysis and related services for patients suffering from end stage renal disease for outside counsel. Developed demonstrative exhibits of the continuum of care including clinical pharmacy regimen and effectiveness of dialysis treatment with the impact on laboratory utilization.  Supervised a team of eight professionals to audit medical records and Medicare charges for laboratory services incorporating the Medicare Composite Rate and 50/50 Rule.
	Lead a review team during a proactive clinical documentation process and billing review of a hospital based dialysis clinic.  Performed interviews with key personnel, identified documentation and billing issues, reported to the chief financial officer and offered recommendations.  The review lead to additional work for the firm in training and education.

Additional Projects and Assignments our team members have completed:

Project management for national health care provider for federal payor compliance audit of 44 home health agencies. This included: identification of any non-compliance regarding Medicare and Medicaid Conditions of Participation, any possible billing and coding errors (unbundling, upcoding, services billed but not provided or not provided at level of coding), development and testing of database auditing tool, coordination of two auditing teams, analysis of raw data, and preparation of final reports. (Medicare Part A)

Development of a work program and database extraction tool to review billing and compliance issues regarding federal payor regulations for a physician’s office. Project management, including audit team member retention and training. Active participation in the medical-legal review of the bills and medical records. Prioritize coding errors and coordinate meetings with healthcare providers and legal staff for interpretation of data. Preparation of report in response to an Office of Inspector General investigation. (TriCare formerly Champus)

Project management and tool development for an internal audit of skilled nursing facilities for a national health care provider pre purchase. Work program included performing site visits, staff (witness) interviews, review of governmental payor claims, medical records, policies and procedures, preparation of report to health law attorneys. Resulted in $12 million savings in purchase price. (Medicare Part A and Part B)

Development of a work program and Access database extraction tool to analyze and report 5 years of ambulance company records (travel logs and claims) responding to Office of Inspector General (OIG) investigation. Project management including audit team retention and training. (Medicare Part A)

Project development for national management firm regarding specialty provider (physicians offices) in billing under "incident to" rule and compliance with federal payor regulations for Medicare Part B coding and billing of services. Develop and project management of work program to determine improper coding of procedures and durable medical equipment, upcoding of evaluation and management (E&M) visits, over and under utilization issues, quality of care, and risk management issues. Formulate a staff development program to bring provider into compliance with regulations. (Medicare Part B)

Review evaluation and management (E&M) documentation and claims for acute hospital emergency room service to determine appropriateness of claims submitted for services provided by Advance Registered Nurse Practitioners (ARNP) and Physician Assistants (PA). Develop work plan to review large volume of emergency room claims for Medicare and Medicaid submitted over a 4-year time span. Develop database for storage, retrieval, and identification of specific encounters in error as per client need. Prepare report to internal legal counsel and work with health law attorneys to self-report errors and repay federal and state programs. (Medicare Part B and Medicaid)

Perform due diligence for national health care provider in preparation of purchase of regional chain of skilled nursing home facilities. Identification of compliance with state and federal regulations for licensure. (Medicare Part A and Part B)

Developed client specific form for documentation of obstetrics visits to conform to Massachusetts Medicaid requirements. Resulted in client obtaining higher reimbursements due to correct documentation being obtained from physicians through the usage of the form. (Massachusetts Medicaid)

Provide guidance to attorney regarding appropriateness of Medicare claims and corrective action plan for mental health provider in preparation of administrative hearing. Resulted in reduction of overpayment and retention of professional license. (Medicare Part B)

Evaluation of operations for on-line claims adjudication of Medicaid prescriptions for national corporation buying a mail-order pharmacy regarding questionable National Drug Codes (NDC) and dispensing practices. (Medicaid)

A civil case audit, involving a home health agency with presences in multiple states, for the United States Department of Justice (DOJ) involving micro-management and review of large volume of medical records and claims. Project included identifying or refuting fraudulent health care schemes and identifying Medicare overpayment. Findings resulted in potential criminal charges being filed against the company. Total recovery was three million ($3 million) dollars returned to the government Trust Fund. (Medicare Part A)

Develop work plan to review large volume of Medicare claims for a statistical sample extending over 7 years. Review line item coding (based on CPT coding – time specific) for acute teaching hospital service to determine appropriateness of claims submitted for services provided by residents and interns. (Medicare Part B)

Review of medical records and claims for neurosurgical patient with insurance coverage under Worker’s Compensation due to disputed hospital charges. Findings included DRG inconsistent, unsigned physician orders, implants without serial numbers, and medically unnecessary in hospital days. The recovered difference between the total charges and findings was $21,000. Worker’s Compensation