Provider Disputes, Compliance and Investigations
The passage of new regulations and healthcare reform combined with a dramatically increased focus on government enforcement and compliance; have created an unprecedented set of challenges for the healthcare industry with the potential to impacting their resources, finances and reputation.
Our professionals have a thorough understanding of the issues facing healthcare providers and bring to bear the deep industry knowledge and experience necessary to assist clients with their most pressing and sensitive matters. We have experience assisting hospitals, long term care centers, outpatient and diagnostic centers, DME providers, Home Health Agencies, Hospice centers and their legal counsel to provide effective solutions for their most complex litigation and compliance issues.
Our consultants provide expert testimony and dispute, compliance and investigation consulting services around a variety of issues, including:
- Fraud and special investigations
- False Claims Act investigations
- Billing and coding claims assessment and documentation
- Contract compliance
- Damages analysis
- Government enforcement support: IROs, CIAs, DPAs and monitorships
- Data breach investigation and response
- RAC audits/investigations
- ICD-10 Investigations
- Medical necessity reviews
- Expert Testimony
Click here to read our insights on healthcare enforcement and compliance & investigation issues.
Disputes, Compliance & Investigations Services for Healthcare Providers
IRO Services Reported to the OIG
A major health system entered into a Corporate Integrity Agreement (CIA) which required Independent Review Organization (IRO) services that were provided by Navigant. The scope of our review included claims sampling, testing of billed claims, and review of the system’s billing, coding, and legal controls. For the claims review, Navigant determined high risk service areas for coding errors and judgmentally selected a sample of claims for review. Coders certified in each of the service areas audited claims and compiled their results in a relational database. The results of our work were reported to the Board of Directors, and subsequently used in the reporting of compliance by the health system to the Office of Inspector General (OIG).
Graduate Medical Education Litigation Support
External counsel for the Dental Residency program at a University engaged Navigant to assit with an extensive review of medical records and other healthcare documentation for various clinics, community health centers and nursing homes. Navigant developed a relational database to store and analyze voluminous amounts of data compiled from the document and data reviews, and subsequently compiled resident rotation schedules for over 500 residents throughout a seven-year period. Additionally, our team analyzed resident salary and stipend data, and program invoices to the sponsoring hospital to determine allowable and non-allowable costs associated with the GME program and regulations for Medicare Cost Report filing purposes.