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.
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.