Federal and state law enforcement and regulatory agencies routinely request information from health care organizations. There are numerous reasons for such requests that range from routine claims monitoring activities, audits by Medicare Administrative Contractors, fraud investigations by Medicare Integrity Contractors, or even investigations by the Department of Justice. Strategic Management’s consultants work side-by-side our clients to assist them in responding promptly and effectively to meet the scope of the government’s request.
Strategic Management assists health care organizations to develop and implement a response team and an approach to take immediate action on critical government inquires. Responses to such government audits and requests must function like clockwork, be rehearsed and deliver information consistently and appropriately with the scope of inquiry. Strategic Management conducts mock audits and statistically valid probe audits to decrease the likelihood of missteps during critical response time. Our advisory services fortify organizations’ response and defense in government inquiries and reduces the likelihood of a larger government investigation or audit, penalties or criminal sanctions.
Strategic Management can work under the direction of legal counsel to assist in the defense of health care organizations subject to demand letters from government agencies. We assist legal counsel to provide supporting and critical examination of the organization’s claims data in preparation for legal action and are prepared to act as an expert witness on behalf of the health care provider or supplier. We further assist by providing strategic and tactical support when our clients come under scrutiny by government agencies and their contractors.
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. We certify that statistical analyses, claims reviews and evaluations are conducted in accordance with the independence and objectivity guidelines of the Generally Accepted Government Audit Standards (GAGAS) of the Government Accountability Office. All work entails an objective and systematic examination of claims against objective criteria drawn from regulations and government program standards. Individuals assigned to perform the independent data analysis and reviews possess the necessary professional proficiency for the tasks required and are always free from impairments that hinder objectivity.
Experienced Team of Auditors
Strategic Management Executive Vice President, Dr. Cornelia Dorfschmid leads a team of certified coders and nurse auditors in making an initial assessment of government inquiries. Our team then evaluates statistical sampling methodology and assesses recovery demands to determine whether established standards of review and statistical auditing were followed, including confidence and precision intervals of overpayment estimates. Our team is qualified to conduct an analysis of findings from government agencies, particularly CMS contractors RACs, MICs, ZPICs, state Medicaid audit and investigation units and DOJ.