Litigation Support

Client Situation 1

A Midwestern 800+ bed Academic Medical Center (AMC) became aware of potential billing errors for services rendered during Medicare beneficiaries’ participation in cancer clinical trials. With self-disclosure on the horizon, the client called on us for assistance.

Core Competency: Audit Strategy Development & Medicare Reimbursement Policy (Clinical Trials Pre- and Post-2000)

Consulting Objectives:

• Quantify the potential overpayment in preparation for voluntary self-disclosure.
• Develop corrective action plan for presentation to the Department of Justice (DOJ) and Office of Inspector General (OIG).

Approach:

• Using our proprietary methodology for conducting coverage analyses, analyze over 200 cancer clinical trials post- 2000 and prepare a Medicare coverage analysis for each trial.
• Train the AMC’s internal audit / compliance staff and outside counsel on the basics of clinical research and how to use the coverage analyses to conduct an audit of patient medical records.

Outcomes:

• The client entered into a Certification of Compliance Agreement (CCA) with OIG as opposed to a more onerous Corporate Integrity Agreement (CIA).
• Civil Monetary Penalties (CMPs) were equal to the amount of the overpayment as opposed to treble damages.

Client Situation 2

A law firm representing a southern Illinois hospital asked us to conduct an investigation with regard to inappropriate billings to the Medicare program for self-administered drugs and reusable equipment. We were also asked to participate in subsequent negotiations with the Department of Justice and Office of Inspector General.

Core Competency: Audit Strategy Development, Medicare Reimbursement Policies & Negotiating Skills

Consulting Objectives:

• Quantify the potential overpayment, if any, based actual overpayments received as opposed to extrapolated audit results.
• Develop a stratified audit sampling methodology more appropriate than the OIG’s standard RATSTATS auditing program and obtain OIG’s approval
• Mitigate or eliminate the potential for imposition of Civil Monetary Penalties (CMPs)

Approach:

• Using the client’s chargemasters, stratify items and services eliminating the need to audit all medical records.
• Conduct medical record audit.
• Obtain detailed payment information for 9,000+ line items over a three-year period and calculate overpayment based on actual amounts received.

Outcomes:

• Stratification of sample audit population resulted in a significant reduction of consulting fees to conduct the investigation.
• Use of actual payments as opposed to extrapolated audit results based on the hospital’s cost-to-charge ratio resulted in a significant reduction in the calculated overpayment.
• The client entered into a Certification of Compliance Agreement (CCA), as opposed to a Corporate Integrity Agreement (CIA), which requires engaging an Independent Review Organization to verify self-audits or conduct claims reviews
• Civil Monetary Penalties (CMPs) were equal to the amount of the overpayment for self-administered drugs and zero for reusable equipment as opposed to treble penalties.

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