Healthcare Fraud & Abuse

Forensus possesses a breadth of healthcare capabilities and routinely prepares analysis involving potential violations of the False Claims Act, Anti-Kickback and Stark laws. Our professionals have significant expertise in the healthcare industry and have served as experts with experience as government investigators, statisticians, internal auditors and compliance professionals.

Along with our traditional litigation support services, we specialize in False Claims Act matters offering a variety of services to plaintiffs, defendants and government agencies alike. Those services often involve serving as a consulting or testifying expert, and they include the following:

Whistleblower & Qui Tam Plaintiffs

  • Claim Development
  • Damage Calculations
  • Sampling & Extrapolation
  • Presentation to DOJ
  • Intervention & Settlement Support
  • Expert Testimony

False Claims Act Defense

  • Internal Investigations
  • Preliminary Quantification
  • Sampling & Extrapolation
  • Ability to Pay Analysis
  • Presentation to DOJ
  • Voluntary Self-Disclosure

Representative Casework

Medicare and Medicaid Fraud

Our professionals have led multiple forensic investigations of provider practices to assess, identify, and quantify issues of improper billing code manipulation. Issues included cases of billing for unnecessary procedures, billing for procedures never performed, “unbundling” of billing codes, and inflation of bills by “up coding”. We have worked closely with Department of Health and Human Services (HHS), Department of Justice (DOJ) and counsel to analyze and synthesize billing data for a variety of clinical providers.

Criminal Healthcare Fraud

Testified as an expert in U.S. District Court rendering opinions on forensic accounting and statistical analysis related to allegations of criminal healthcare fraud. Statistically sampled and analyzed medical equipment billing and coding records along with patient medical records to identify indicia of fraud and to calculate financial damages.  We analyzed over 100,000 lines of hospital billing data to determine the amount of reimbursement from Medicare/ Medicaid related to the doctors and practice groups in question.

Stark Laws Violations

We have been retained as a healthcare fraud expert to review contracts between various physician practice groups and a not-for-profit hospital over concerns of violations of physician self-referral laws. We identified, collected, and processed electronic data from the company’s email and accounting systems, and compiled payments by the hospital to the doctors/ physician groups.   We analyzed over 100,000 lines of hospital billing data to determine the amount of reimbursement from Medicare/ Medicaid related to the doctors and practice groups in question.

Post-Acquisition Investigation

Retained as a testifying expert on behalf a $100 million pharmacy services company to conduct an internal investigation related to the company’s acquisition. Analyzed financial records related to payer obligations for federal, state, and third party payments.   Quantified in excess of $50 million of financial damages due to improper billing and accounting practices.

CMS Repayment Appeals

Retained on multiple occasions as a testifying expert on behalf of a physician practices to assess the statistical validity and conclusions of Centers for Medicare and Medicaid Services (CMS) demands for repayment. Authored expert reports in support of the practice’s repayment appeal.

False Claims Act – Whistleblowers

Our team led the forensic accounting analysis of whistleblower allegations at a leading national therapy provider. The provider was an active acquisition target throughout the investigation. Allegations included improper application of billing codes and overbilling of third party payers in excess of $25 million over three years. We designed and selected a Statistically Valid Random Sample (SVRS) of patient records from over two million visits to quantify improper billings, assess patterns in billing activity, and extrapolate results of the sample. Prepared and presented summary analysis to clients and counsel, potential acquirers, and the state’s Attorney General’s office.

Improper Marketing Practices

Our professionals led the investigation of a Fortune 100 medical device manufacturer to assess the company’s compliance with policies related to payments and gratuities made to healthcare providers. We identified specific improper payments disguised as charitable sponsorships, honoraria, and R&D equipment. Led the interviews of over 50 internal employees and customers including clinical, marketing, accounting, and operations personnel.

Federal Anti-Kickback Law

Our professionals led the financial investigation of a complex network of physicians to identify the structure and timing of allegedly improper referrals and kickbacks. Analyzed the business and personal financial records of subjects to create a comprehensive timeline illustrating the financial organization illicit network. While this investigation originally involved two physicians, our investigators identified a complex network of over 35 physician groups, and three additional kickback networks.

False Claims Act – Whistleblowers

Our professionals led the investigation of whistleblower allegations at a Fortune 100 device manufacturer serving as a healthcare fraud expert. Allegations included inflation of costs on over $650M of cost-plus contracts for the U.S. Government, and improper application of government Cost Accounting Standards (CAS) in accordance with the Federal Acquisition Regulation (FAR). Reviewed over five years of cost disclosure documentation and worked closely with the DCAA to assess the materiality of issues identified. Identified multiple process weaknesses and worked closely with the client to remediate deficiencies resulting in no financial sanctions against the company.

healthcare fraud expert

chris haney

healthcare fraud expert healthcare compliance expert