BlickenWolf - Our Team

Jim Vagenas works exclusively in the healthcare industry investigating known or suspected fraud, as well as providing fraud awareness and fraud prevention training to clients. Jim specializes in assisting healthcare providers with risk assessments as part of the overall development and implementation of corporate compliance and corporate integrity programs.

Jim assists hospitals, physician groups, and other healthcare organizations in achieving and maintaining regulatory compliance. He also has extensive experience developing and implementing Corporate Integrity Agreements (CIAs), including annual compliance audits and the mandatory training required under CIAs.

Prior to joining BlickenWolf, Jim worked as a manager for America’s largest non-profit health maintenance organization, where he played an instrumental role in implementing a corporate compliance program as mandated by CIAs imposed by the Office of the Inspector General (OIG). Jim’s previous experience also includes:

Working as a consultant and manager in Forensic and Investigative Services practices in two separate international professional services firms
Serving as an Internal Compliance Analyst for the largest and most experienced health insurance company in Illinois
Serving as a Criminal Investigator in the State Attorney General’s Office Medicaid Fraud Control Unit, where his efforts involved federal task force investigations in conjunction with the Federal Bureau of Investigation (FBI), the OIG, the U.S. Postal Inspectors, the Internal Revenue Service (IRS), and various local law enforcement agencies
Working as a Criminal Investigator for the County Prosecutor’s Office, where he routinely dealt with the investigation of all types of felony white-collar crime
Engagement manager for various Corporate Integrity Agreements, including training, billing engagements, and compliance engagements
Performed Voluntary Disclosure engagements for various types of providers
Performed risk assessments and diagnostic reviews of various types of providers in connection with investigations of compliance issues associated with numerous federal and state healthcare programs
Developed, implemented, and monitored compliance programs in a variety of healthcare settings, from stand-alone facilities to multi-state systems
Conducted focused reviews in the areas of 72 Hour Rule, Laboratory Bundling/Unbundling, Physician Assisted Teaching Hospital (PATH), and Emergency and Management (E/M) coding
Performed assessments of hospital Medicare billing systems in connection with issues regarding supervision of resident services
Performed evaluations of physician group billing practices associated with hospitals
Developed operating procedures for a Blue Cross/Blue Shield plan’s operation in the Chicago and Detroit regional offices
Performed random audits in departmental areas to ensure that government-imposed corrective measures had been implemented
Evaluated and analyzed employee work flows for inefficiencies
Identified strengths and weaknesses within departmental processes and assisted in implementing corrective action plans
Monitored productivity to determine if quality performance standards were being met
Established departmental policies and procedures that were in compliance with the Health Care Financing Administration (HCFA), the Office of the Inspector General (OIG), and U.S. General Accounting Office (GAO) regulations

Jim’s work has involved numerous grand jury investigations performed in conjunction with the county Police Department, the State Police, and the State Board of Accounts. Working in enforcement, Jim has:

Managed an investigation of a group of dentists that were fragmenting their Medicaid claims by billing for each individual tooth instead of billing for a complete set of dentures. The group received over $13 million in overpayments by utilizing this billing scheme. This investigation led to a felony plea bargain by the dental group.
Assisted in the investigation of a physician who was billing the Medicare and Medicaid Programs for services not rendered and participated in the prosecution that led to a felony conviction of this physician. Jim received a Special Achievement award from U. S. Attorney’s Office for his involvement in this case.
Conducted an investigation for a durable goods manufacturer (purchaser) that purchased a home protection devices company (seller). After the purchaser assumed control of the seller’s financial systems, it became apparent that the seller might have violated the terms of the purchase agreement with respect to the reserve amounts. Conducted an extensive investigation of the company’s pre and post acquisition reserve balances based the seller’s methodology. The results of the analysis were presented to the seller’s Board of Directors and legal counsel to determine whether it was prudent to pursue litigation regarding the matter.
Assisted in the grand jury investigation and the ultimate criminal prosecution of the largest tax embezzlement scheme in county history.
Conducted an investigation of a nursing home bookkeeper who was embezzling funds from the a nursing home resident’s patient personal account. The bookkeeper was convicted of felony forgery.
Investigated a home health agency office manager for back-billing “series” patients’ accounts when, in fact, the patients did not actually receive any services. Testified as a summary witness for the U.S. Attorney’s Office case, which lead to a felony conviction.
Conducted an investigation into potential fraudulent activity for a retail grocery chain. The company’s accounts payable clerk had disappeared for approximately a month without explanation. The company was days from disclosing its year-end financial results and was concerned that the accounts payable clerk may have participated in irregular transactions that would have resulted in material misrepresentation of the company’s financial statements. Conducted numerous interviews of key personnel and analyzed accounting system data to provide the company reasonable assurance that the clerk did not initiate or condone any fraudulent transactions. Presented investigative findings to the company’s Board of Directors and legal counsel to aid in their assessment of possible financial restatement.

Jim earned a bachelors degree from Indiana University. His education includes a Healthcare Fraud Training Course at the Federal Law Enforcement Academy and U.S. Department of Justice-sponsored training in financial investigations, asset forfeiture, drug diversion, and advanced interviewing and interrogation. Jim served eight years in the U.S. Army Reserve. He is a member of the Healthcare Financial Management Association (HFMA).