Assisting Hospitals, Pharmacies, DME Companies, and Other Providers with All Aspects of Healthcare Compliance
Compliance Team Lead – Timothy E. Allen | Former Special Agent (U.S. Secret Service & DOJ-OIG)
If you are in the healthcare industry, you need to prioritize compliance. Professionals and organizations involved in all segments of the industry are subject to extensive legal and regulatory requirements, and failure to meet these requirements can have substantial ramifications.
These ramifications can range from recoupment liability and pre-payment review to Medicare exclusion, fines, and federal imprisonment. Federal authorities are cracking down on healthcare providers and others in the industry, and, for those that fail to prioritize compliance, it is likely only a matter of time until they face the consequences. While federal investigations targeting large-scale Medicare fraud schemes make headlines, it is the investigations that don’t make headlines that put most legitimate providers and businesses in jeopardy.
Centuries of Healthcare Experience
We are a team of former federal agents who have centuries of combined experience in the areas of healthcare compliance and healthcare fraud investigations. With prior careers at the U.S. Department of Health and Human Services (DHHS), U.S. Department of Justice (DOJ), and Drug Enforcement Administration (DEA), we know healthcare compliance inside and out. We know how healthcare providers can—and should—use compliance to their advantage, and we have seen what can happen when providers and other businesses fail to do what is necessary.
At Corporate Investigation Consulting, we take a tailored, team approach to healthcare compliance consulting. We focus on each client’s specific needs, and our consultants work together while offering advice in their respective areas of expertise. This ensures that each client receives the full benefit of our former federal agents’ collective experience, and it ensures that each client has the compliance tools it needs to avoid federal scrutiny—and withstand it if necessary.
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.)
Strategic Consulting for All Areas of Healthcare Compliance
We assist hospitals, doctor’s offices, clinics, laboratories, pharmacies, home health agencies, durable medical equipment (DME) companies, and other clients with all areas of healthcare compliance. While most healthcare industry participants are aware that they have compliance obligations, in our experience few have a clear understanding of just how expansive these obligations are. Compliance has implications for all aspects of healthcare providers’ and other organizations’ operations, and deficiencies in even a single area can raise red flags that trigger a government audit or investigation.
Our healthcare compliance consulting services encompass areas including (but not limited to):
- Medicare, Medicaid, and Tricare Billing and Coding
- Private Insurance Billing and Coding
- Medical Necessity Determinations and Documentation
- HIPAA Compliance
- DEA Compliance
- FDA Compliance
- Cardiac Testing, Pain Management, CGM, and Other Specific Areas of Compliance
- Telemedicine and Telehealth Compliance
- Anti-Kickback Statute and Stark Law Compliance
- Healthcare Marketing Compliance
Healthcare entities will often have non–healthcare-specific compliance obligations as well. For example, providers that collect patients’ personal, health, and financial information must give due consideration to cybersecurity. Implementing adequate cybersecurity measures is critical not only for HIPAA compliance but also for meeting other compliance obligations. In addition to former federal agents who are experts in healthcare compliance, our team includes former federal agents who are experts in other areas of compliance. As a result, we are truly able to offer comprehensive compliance consulting services that fully meet the needs of entities in the healthcare industry.
Comprehensive and Tailored Healthcare Compliance Programs
Whether your healthcare compliance program needs an overhaul or you need to start from scratch, we can provide a comprehensive and custom solution focused on the specific risks your business or practice faces on a day-to-day basis. Our services include:
Policies, Procedures, and Standards of Conduct
We assist with the preparation of all written policies, procedures, and standards of conduct necessary to establish and maintain compliance. Our consultants can review your business’s or practice’s existing compliance documentation to determine what updates and modifications are necessary, or we can work with you to develop an entirely new set of compliance documents. Comprehensive and custom documentation is the foundation of a successful healthcare compliance program, and we work closely with our clients’ key stakeholders to ensure that they have the documentation they need.
Designation of Compliance Officers and Committees
All entities involved in the healthcare industry should have a compliance officer; and, in most cases, a compliance committee. The compliance officer’s role is critical, whether the officer devotes all of their time to compliance or also serves the organization in another capacity. We assist our clients with selecting their compliance officers and committee members, as well as with documenting all relevant roles so that they can prove their good-faith efforts when necessary.
Compliance Program Training and Implementation
Training and implementation are also essential aspects of healthcare compliance. Once our clients have sound compliance programs in place, we assist them with educating all relevant personnel and otherwise implementing their programs on an organization-wide scale. Depending on the size and nature of the business or practice, this could include everything from posting signs and establishing compliance hotlines to negotiating contracts with billing administrators and other third parties.
Compliance Program Monitoring and Auditing
Healthcare compliance is an ongoing process. Too often, healthcare providers of all sizes assume that it is enough simply to “have” a compliance program. But this is not the case. Healthcare entities must effectively monitor their compliance efforts and compliance obligations on an ongoing basis, and they must conduct periodic audits so that they can identify and address any issues before they lead to government scrutiny.
Compliance Program Enforcement
Another often-overlooked aspect of healthcare compliance is compliance program enforcement. When individual personnel are responsible for compliance violations, there should be consequences. Whether these consequences take the form of a reprimand, termination of employment, or something in between needs to be determined case-by-case in light of the severity of the issue involved. Fostering a culture of compliance through an appropriate advancement and reward system can be a highly effective strategy as well. We help our clients explore their options and put suitable enforcement systems in place.
Government Audit and Investigation Preparedness
While healthcare entities can (and must) undertake efforts to mitigate their risk of facing government scrutiny, they cannot prevent state or federal authorities (or the government’s “fee-for-service” contractors) from looking around if they choose to do so. With this in mind, an effective compliance strategy will also involve government audit and investigation preparedness. With our consultants’ prior experience as federal agents, we are well versed in the government’s audit and investigation tactics, and we are able to help our clients proactively position themselves to come out of these inquiries unscathed.
FAQs: Understanding the Importance of Healthcare Compliance
How important is healthcare compliance?
Healthcare compliance is extremely important. Not only are many of the nation’s healthcare laws and regulations designed to protect patient safety and promote patients’ rights, but noncompliance also presents substantial risks for entities and individuals in all segments of the healthcare industry. The DOJ and other federal authorities vigorously enforce providers’ compliance obligations, and the penalties for noncompliance can be severe.
What are the risks for healthcare providers that aren’t compliant?
For healthcare providers, noncompliance can lead to civil or criminal penalties. In civil cases, which typically involve allegations of unintentional healthcare fraud, penalties can include recoupments, fines, and program exclusion. In criminal cases, providers can face these penalties plus the possibility of federal incarceration.
How do I know if my healthcare practice or business is fully compliant?
Determining whether your healthcare practice or business is fully compliant requires a comprehensive internal compliance audit. When we take on new clients, conducting an audit is always our first step. This ensures that we know where our clients’ risks lie, and it ensures that we know exactly what is needed in light of the unique aspects of our clients’ operations.
What does it take for healthcare providers to establish compliance?
Establishing healthcare compliance requires a dedicated, multifaceted, and long-term approach. There is no easy solution. Providers and other businesses must dedicate the necessary resources to compliance, and they must commit themselves to maintaining compliance on an ongoing basis.
Do healthcare organizations need to engage an outside compliance firm?
Most healthcare organizations will need to engage an outside consulting firm to assist with their compliance efforts. The universe of compliance obligations, and the steps that must be taken in order to meet these obligations, are simply too vast and too complex for most providers and businesses to manage effectively on their own. Avoiding oversights and other potentially costly mistakes requires the advice and insights of a team of expert consultants who focus on healthcare compliance on a daily basis.
Speak with a Healthcare Compliance Consultant in Confidence
If you would like to speak with a healthcare compliance consultant at Corporate Investigation Consulting, we invite you to arrange a complimentary initial consultation. We work with healthcare organizations of all sizes nationwide. To schedule an appointment at your convenience, please call 866-352-9324 or tell us how we can help online today.