Responding to Government Audits and Requests

Federal and state law enforcement and regulatory agencies and their contractors routinely contact health care organizations with data or information requests. There are numerous reasons that range from routine claims monitoring activities or audit activities by a Medicare Administrative Contractor (MAC), to fraud investigations by a Medicare Integrity Contractors, such as a ZPIC or even the Department of Justice (DOJ). In most cases, the government agency or contractor sends a letter that indicates the purpose and objective of the intended review, often including a request for particular records.

It is critical that an immediate internal inquiry is initiated and an internal response team is activated. Response to such government audits and requests must function like clockwork and be rehearsed. It is vital to respond to any official requests for information consistently and appropriately. However, care must be taken to ensure that those that make contact are in fact duly authorized representatives of government agencies and that privacy right of patients and staff is not compromised.

A proactive approach to government audits, including the preparation and implementation of a pre-inspection action plan, including a dry run using a “mock audit” or statistically valid probe audit will significantly decrease missteps in the response or the likelihood of a government investigation or inspection, large penalties and criminal sanctions; and if such an activity is initiated will fortify the response and defense of the organization.

If you would like to discuss your situation with a specialist, please contact us today. You can call us at (703) 683-9600 or fill out our online contact form.

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Litigation Support

Strategic Management is frequently engaged under direction of legal counsel to assist in the defense of organizations that have been made subject of demand letters by governmental entities or their agents. We fully defend all of our work before any third party or judicial entity. Strategic Management is experienced and prepared to work with counsel and act as an Expert Witness on behalf of the provider/supplier for the work performed.

We can assist organizations with strategic and tactical support when they come under scrutiny by government agencies and their contractors. Organizations should understand the timelines and due dates of all requests, including Additional Documentation Requests (ADRs) by Medicare contractors performing data analysis and medical reviews. The first line of defense to government questioning of business practices and claims submission is to be able to fully assess and evaluate the direction and objectives of these auditors and examiners and to appropriately and timely respond, but also to assess internally the immediate any secondary risk from the government’s request, and any impact from overpayment extrapolations. In addition, there may be spillover vulnerability from a confirmed claims risk in one area that is paralleled in or impacts another claims area not under scrutiny.

Strategic Management has a first class team led by the firm’s Executive Vice President, Dr. Cornelia Dorfschmid in making an initial assessment of the meaning and direction of queries by outside parties. Our team can quickly evaluate any statistical sampling methodology and assess recovery demands of these parties to determine whether they followed established standards of review and statistical auditing, including confidence and precision intervals of overpayment estimates.

Strategic Management can conduct an analysis of findings from government agencies, particularly CMS Contractors, such as the Recovery Audit contractors (RACs), Medicaid Integrity Contractors (MICs), Zone Program Integrity Contractors (ZPICs), as well as State Medicaid OIG Audit & Investigation units, and Department of Justice investigation units. Our team can quickly conduct an independent analysis of claims processes or transactions and recover demands to determine the proper levels of any overpayments, assist organizations in developing a response to those findings, and provide litigation support working with counsel.

Certified Adherence to Government Standards

Strategic Management’s claims review protocol follows medical review and statistical auditing best practices, including application of OIG RAT-STATS, as applicable.

Strategic Management certifies that we conduct the statistical analyses, claims reviews, and evaluations in accordance with the independence and objectivity guidelines of the Generally Accepted Government Audit Standards (GAGAS) of the Government Accountability Office (GAO). The work entails an objective and systematic examination and analysis of claims or other documents against objective criteria drawn from the government regulations and program standards. Individuals assigned to perform the independent data analyses and reviews possess the necessary professional proficiency for the tasks required and are always free from impairments that hinder objectivity. In performing their data analysis and reviews, they exercise due professional care in the review and in preparing the report of findings. The review reports will always present factual data accurately, fairly, and objectively with findings, determinations, and conclusions presented in a persuasive manner. All recommendations and suggestions will arise from findings, and all findings will be supported with documentation maintained in the work papers.

If you would like to speak with a specialist about our processes, please contact us today.

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