Case Studies: Corporate Investigations
Academic Medical Institution Billing and Coding Practices
Investigation and Voluntary Disclosure
BlickenWolf was retained by a state academic medical institution’s
counsel to investigate its client’s billing and coding practices. The
institution, which owns and operates a number of physician clinics,
discovered through the internal compliance office’s billing and coding
audits that a large number of physician assisted services were not
documented according the federal and State documentation requirements.
The audits revealed that documentation did not sufficiently support the services and medical codes that were charged to federal payers. BlickenWolf conducted a probe sample of both Medicare and State Medicaid claims. Subsequently, we conducted an analysis of expended samples of each claim type and calculated the appropriate overpayment amounts using statistical extrapolation, resulting in a disclosure and repayment to the Office of Inspector General (OIG).
Academic Medical Institution Investigation
BlickenWolf was engaged by a major academic medical institution’s legal
counsel to perform a shadow audit of certain patients’ billing and
medical record documentation that were provided to the U.S. Attorney’s
Office in response to a subpoena that was issued to the provider.
We conducted extensive analyses of the client’s billing and medical
record documentation to determine the direction of the government’s
Grand Jury investigation and to provide plausible legal strategies
for the institution’s counsel.
Physician Evaluation and Management Coding Investigation
BlickenWolf was retained by counsel to perform an independent investigation
of certain physician coding and billing for Evaluation and Management
(E&M)
services provided in a hospital setting. The focus on certain E&M services was the result of allegations raised by a former hospital employee.
Specifically, the employee alleged that hospital management was aware
of inappropriate E&M coding, but did not institute a corrective action plan. Based on our findings,
counsel recommended that the hospital self-disclose all overpayment
amounts that resulted from inappropriate E&M coding and billing to the Office of Inspector General (OIG).
Hospital System Emergency Department Investigation
BlickenWolf was engaged by a hospital system’s outside counsel to assist
in the investigation of potential False Claims Act violations. The
U.S. Attorney’s Office subpoenaed patient billing and medical record
documentation in connection with the allegations. We conducted extensive
analyses of the client’s billing and medical record documentation
to assess whether the provider intentionally submitted false claims
to governmental payers. Our analysis provided legal counsel with
strategies to defend against the potential violations.
Third Party Administrator Payer Investigation and Litigation
Support
BlickenWolf was retained by counsel of a third party administrator
(TPA) of medical insurance plans. The TPA, which represented employees
of nearly 100 companies and governmental organizations of varying size,
was charged with seven counts of felony theft. The State contended
that the TPA straddled claim payments across different fiscal years
to avoid reaching cumulative claim amounts, which would disqualify
it from receiving bonus payments from the reinsurer. We assisted counsel
in building its defense beyond the analysis of discovery documentation,
including the creation of financial impact scenarios and industry cost
models. The results of our analysis culminated in our provision of
expert testimony that proved to be the backbone of the TPA’s defense.
The jury subsequently exonerated the TPA of all charges.
