Handling Internal Audits, Compliance Inspections, and More for Healthcare Companies
Corporate Healthcare Fraud – Timothy E. Allen | Former Special Agent (U.S. Secret Service & DOJ-OIG)
Healthcare is among the most heavily regulated industries in the United States. Due in large part to rampant fraud (which costs private insurers and government programs tens of billions of dollars annually), federal authorities such as the U.S. Department of Justice (DOJ) and the U.S. Department of Health and Human Services Office of Inspector General (DHHS OIG) vigorously enforce businesses’ compliance obligations. Federal investigations targeting healthcare providers and other entities are common, and it is not unusual for healthcare fraud cases to involve tens or hundreds of millions of dollars in potential liability.
So, is your healthcare business federally compliant? If you are not sure, you are not alone. Federal healthcare compliance is inordinately complicated, and simply understanding your business’s obligations can be extremely difficult. But this complexity is not an excuse for noncompliance—the DOJ and DHHS OIG have made this clear—and even simple mistakes can lead to drastic consequences.
Healthcare Compliance Consultants
At Corporate Investigation Consulting, we help all types of healthcare businesses establish, maintain, and prove federal compliance. We work with private practices, physician groups, clinics, hospitals, pharmacies, laboratories, and durable medical equipment (DME) companies—among many other clients.
To advise our clients effectively, our consultants rely on decades of experience working both inside the federal government and in the private sector. When you choose Corporate Investigation Consulting, your business’s team will include:
- Former Assistant Special Agent in Charge with DHHS OIG
- Former Special Agents and Special Agent-in-Charge with the U.S. Drug Enforcement Administration (DEA)
- Former Special Agent with the DOJ Office of Inspector General (DOJ OIG)
- Former Special Agents and Supervisory Special Agent with the Federal Bureau of Investigation (FBI)
- Former Medicaid Supervising Investigator
Put our highly experienced team on your side
Roger Bach
Former Special Agent (OIG)
Timothy E. Allen
Former Senior Special Agent U.S. Secret Service
Chris J. Quick
Former Special Agent (FBI & IRS-CI)
Maura Kelley
Former Special Agent (FBI)
Ray Yuen
Former Supervisory Special Agent (FBI)
Michael S. Koslow
Former Supervisory Special Agent (DOD-OIG)
Marquis D. Pickett
Special Agent U.S. Secret Service (ret.)
Internal Healthcare Compliance Inspections
When it comes to federal healthcare compliance, there is no room for error. Business owners and practitioners need to have unwavering confidence in their compliance programs. If your business’s compliance program has never been stress tested, then the reality is you do not know if the program is as effective as it should be.
When a client engages Corporate Investigation Consulting for healthcare compliance, a key aspect of our services involves conducting an internal healthcare compliance inspection. This allows us to identify all shortcomings and tailor our subsequent steps accordingly. When we conduct internal healthcare compliance inspections for providers and other businesses, we have three main priorities:
1. Stopping Any Current Violations
First and foremost, we need to make sure your business ceases any current violations. If your business is improperly billing Medicare, Medicaid, Tricare, private insurers, or any other payors, you need to know about it, and you need to put a stop to it immediately.
As a result of our experience, we know how to spot all forms of billing fraud. We know all of the hallmarks and red flags, and we are fully up-to-date on the latest changes to the federal billing rules and regulations. In most cases, billing errors result from a misunderstanding of the rules that apply. Billing personnel believe they are following the law—but they are not. As a result, they tend to make the same mistakes over and over, and this means that the business’s liability risk is substantial.
2. Updating Your Business’s Compliance Policies and Procedures
Once we know where the shortcomings in your business’s compliance policies and procedures lie, we can implement appropriate fixes. The amount of work this entails will depend on the scope and nature of the issues we uncover during our internal inspection. Our goal is to help every client establish and implement a comprehensive and updated healthcare compliance program as efficiently and cost-effectively as possible. We do what needs to be done—nothing more and nothing less.
3. Documenting Good-Faith Efforts to Maintain Compliance
In addition to developing an effective healthcare compliance program, businesses in the industry must take adequate steps to document their good-faith efforts to maintain compliance on an ongoing basis. In the event of a federal audit or investigation, this type of documentation can prove crucial.
Federal agents expect healthcare entities to be able to affirmatively demonstrate compliance. When they cannot, this automatically raises red flags. Conversely, when a business is able to use documentation it has on hand to show that it is doing everything it can to bill within the confines of the law, this can streamline the investigative process and facilitate a favorable outcome.
Responding to Federal Healthcare Fraud Investigations
In addition to conducting internal inspections and helping businesses establish and maintain compliance, we also consult with entities that are facing federal healthcare fraud investigations. Perhaps it could go without saying, but these are extremely serious matters. Federal investigations can lead to civil or criminal penalties—including loss of program eligibility, fines, recoupments, treble damages, and even federal imprisonment.
When facing a federal healthcare fraud investigation, it is critical to be able to view the investigation from the government’s perspective. Why is the government investigating? What are its specific concerns? What are its goals? Are any other businesses being targeted? With our consultants’ past experience conducting federal healthcare fraud investigations, we are able to offer unique insights that our clients can use to make smart decisions and protect themselves effectively.
If a federal healthcare fraud investigation presents a risk of exposure (i.e., if the targeted business has a history of billing violations), a tactful approach is required. Voluntary disclosure might be the best approach, but it also might not. Furthermore, when acknowledging past mistakes affords the greatest opportunity to avoid unnecessary consequences, it will generally be necessary to demonstrate that the business is already undertaking efforts to prevent recurrence in the future. We help our clients decide how best to move forward, and we ensure that they have the information, tools, and documentation needed to favorably resolve their issues with the federal government.
FAQs: How, When, and Why to Establish Federal Healthcare Compliance Audits
How important is strict Medicare, Medicaid, or Tricare compliance?
Strict compliance with the rules and regulations of all federal healthcare benefit programs is extremely important. The same goes for private health insurers’ rules and regulations as well. Participating businesses are subject to stringent oversight and, if an audit or investigation reveals any instances of noncompliance, this can lead to steep penalties—not to mention even greater scrutiny going forward.
How can I be sure that my business’s healthcare billings are federally compliant?
The only way to make sure your business’s healthcare billings are federally compliant is to conduct an internal compliance inspection. This should involve a comprehensive, invasive, and in-depth assessment of the adequacy of your business’s current compliance program. The goal should be to identify any and all shortcomings so that they can be addressed before they create exposure in an audit or investigation.
What if I know my business has improperly billed Medicare, Medicaid, or Tricare in the past?
If you know your business has improperly billed Medicare, Medicaid, Tricare, or any other payor, this is an issue that you need to address proactively, both in terms of remedying the mistake and making sure it does not happen again. We recommend conducting an internal inspection promptly, documenting all efforts to identify the source and scope of past billing mistakes, and adopting updated compliance documentation that addresses all areas of concern.
How can I keep my business’s federal healthcare compliance program up-to-date?
Federal and private billing rules and regulations change regularly, and this means that maintaining an up-to-date compliance program can be very challenging. To avoid falling behind, you need to work with a team of consultants who have an intimate understanding of your business’s current compliance obligations. With our focus on the healthcare sector, we are tuned in to the latest developments, and we look for outdated policies and procedures by default when conducting internal compliance inspections.
What should I look for in a federal healthcare compliance consultant?
When choosing a federal healthcare compliance consultant for your business, the most important consideration is relevant experience. This includes experience as a federal healthcare fraud investigator, as former agents can offer unique insights into the federal compliance regime. At Corporate Investigation Consulting, all of our consultants have prior federal government experience, and our team approach ensures that all of our clients receive the full benefit of the collective insights our consultants have to offer.
Schedule a Confidential Consultation at Corporate Investigation Consulting
If you would like to know more about our services for corporate healthcare fraud audits, inspections, and investigations, we encourage you to get in touch. Please call 866-352-9324 or contact us online to schedule a confidential consultation today.