Fraud and Abuse Investigations 101

This online, on-demand course covers what you need to know before your first health care fraud and abuse investigation, delivered in crystal-clear, bite-sized learning moments.

In each self-paced module, you’ll click through concise explanations, examples, and microvideos in which experienced attorneys share their personal insights. Self-assessments are included throughout the course to keep you engaged and on track.

Based on a book by Paul W. Shaw and Robert A. Griffith, this course is perfect for counselors and stakeholders new to health law, compliance, or fraud and abuse.

Group licenses are available. For information, email [email protected].

Approved for CLE in most jurisdictions and approved for CCB. Please note that the actual number of CLE credits may vary from state to state. The maximum number of credits available is approximately 4.75.

“This course provides an outstanding user-friendly introduction for anyone to the complicated world of health care fraud and abuse enforcement.” –Greg Demske, Goodwin Procter LLP

“This new format combines excellent legal issue coverage with immediate insider information to allow the viewer to use the learnings quickly. It connects the legal analysis with real world use cases. It’s a very engaging way to deliver education.” –Tizgel High, Prime Therapeutics

“This course provides a good introduction to people new to the industry or those who want a refresher on fraud and abuse investigations.” –Tony Maida, McDermott Will & Emery LLP

What This Course Covers

Module 1: Introduction to Fraud and Abuse in Health Care (20 Minutes)

OVERVIEW

• Why Do I Need to Worry About Fraud and Abuse?
• The Domino Effect of an Investigation
• How you Respond Matters

THE POTENTIAL OUTCOMES OF AN INVESTIGATION

• Exclusion from Medicare & Medicaid
• Denial or Revocation of Enrollment
• Suspension of Payments
• State Medical Boards and Licensing
• Medical Staff Credentialing

Speaker: Amanda B. Hill

Module 2: Overview of Enforcement Agencies (30 Minutes)

OVERVIEW

• The Enforcement Agencies

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

• The Agency That Gives Us Medicare
• Centers for Medicare & Medicaid Services
• Office of the Inspector General

U.S. DEPARTMENT OF JUSTICE

• DOJ: The Country’s Primary Enforcement Agency
• The Federal Bureau of Investigation
• Other Federal Agencies with Investigation Units

MEDICAID

• Overview of State Medicaid Programs
• Medicaid Fraud Control Units

CONTRACTORS

• An Overview of Contractors
• Medicare Administrative Contractors
• Medicare FFS Recovery Audit Contractors
• Medicaid Recovery Audit Contractors
• Unified Program Integrity Contractors

PRIVATE CITIZENS AND INSURERS

• Qui Tam Lawsuits
• Lawsuits by Private Insurers

Speaker: Gregory Demske

Module 3: The Statutory Framework for Fraud and Abuse Investigations (30 Minutes)

FEDERAL CRIMINAL STATUTES

• An Overview of the Federal Criminal Statutes
• Health Care Fraud Statute
• False Statements Relating to Health Care Matters
• Obstruction of Criminal Health Care Investigations
• Theft and Embezzlement
• Medicare and Medicaid Patient Protection Act
• Anti-Kickback Statute
• False Statements
• Obstruction of Justice
• Conspiracy

FEDERAL CIVIL STATUTES

• Food, Drug, and Cosmetic Act
• Physician Self-Referral Statute
• Civil False Claims Act
• Failure to Report and Refund Overpayments
• Qui Tam Actions

STATE LAWS

• State Criminal Laws
• State Civil False Claims Acts

ADMINISTRATIVE SANCTIONS

• Civil Monetary Penalties
• Exclusions

Speaker: Gregory Demske

Module 4: Requests for Information, Investigatory Demands, and Subpoenas (20 Minutes)

HHS OFFICE OF INSPECTOR GENERAL

• Requests for Information
• Administrative Subpoenas
• Interviews by the OIG and FBI
• Demand for Immediate Access

U.S. DEPARTMENT OF JUSTICE

• HIPAA Administrative Subpoenas
• Civil Investigative Demands
• Grand Jury Subpoenas
• Controlled Substances Investigation
• The Federal Substance Abuse Confidentiality Act

Speaker: Amanda B. Hill

Module 5: Responding to Requests for Information (15 Minutes)

OVERVIEW

• Investigatory Requests Are a Serious Matter

YOU GOT A SUBPOENA…NOW WHAT?

• Contact the Government
• Review the Scope of the Request/Subpoena
• Determine Where the Information is Maintained
• Narrow the Scope
• Remember the Deadline!
• Appoint an Independent Custodian
• Ensure the Integrity of the Requested Information
• Implement a Document Hold Policy and Conduct Forensic Imaging

Speaker: Ritu Kaur Cooper

Module 6: Handling On-Site Demands for Records and Access (15 Minutes)

THE EMPLOYEES

• Prepare Your Employees

YOU’LL NEED AN ATTORNEY

• The Role of the Provider’s Attorney

PROVIDING ACCESS TO THE INVESTIGATORS

• Search Warrants
• What to do When the Investigators Show Up

ELECTRONIC AND VIDEO SURVEILLANCE

• Overview of Government Surveillance
• Tape Recorded Conversations
• Video Surveillance

Speaker: Ritu Kaur Cooper

Module 7: Retaining an Attorney During the Investigation (10 Minutes)

LEGAL REPRESENTATION

• Should I Get My Own Lawyer?
• One Case, Many Clients: The Potential for Conflicts of Interest
• Weighing the Pros and Cons
• Breaking Up Is Hard To Do—Ending the Relationship

NON-TARGET & TARGET EMPLOYEES

• Hiring an Attorney for Non-Target Employees
• Paying the Legal Fees of Targeted Employees

THE GOVERNMENT

• Notifying the Government About Who Has Lawyers

AGREEMENTS

• Joint Defense Agreements

Speaker: Tony Maida

Module 8: Internal Audits and Investigations (20 Minutes)

A (VERY) BRIEF HISTORY

• Internal Inquiries, Then and Now

STATUTES AND REGULATIONS

• The Big 3: Stark, SOX & ACA
• The Physician Self-Referral Law
• The Sarbanes-Oxley Act
• The Affordable Care Act

HOLDING PROVIDERS ACCOUNTABLE

• Agreements, Duties, and Guidelines
• Corporate Integrity Agreements
• The Fiduciary Duty of Corporate Directors and Officers
• Federal Sentencing Guidelines for Organizations
• OIG’s Compliance Program Guidance

PLAN, IMPLEMENT, AND FOLLOW-UP

• The General Pattern of Internal Inquiries
• Is an Inquiry Warranted?
• Develop and Implement a Plan of Inquiry
• Refund Amounts Due
• Develop and Implement a Corrective Action Plan
• Follow-up on the Corrective Action Plan

PRESERVING PRIVILEGES

• Preserving Privileges During the Internal Inquiry

Speaker: Tony Maida

Module 9: Statistical Sampling (10 Minutes)

STATISTICAL SAMPLING

• How a Statistical Sampling Audit Is Initiated
• How a Statistical Sampling Study is Conducted

CHALLENGING THE METHOD

• Bases on Which Statistical Samplings Can Be Challenged

CONFRONTING A STATISTICAL SAMPLING STUDY

• Re-examine the Audited Cases
• Hire Outside Experts & Consultants

Speaker: Tizgel K.S. High

Module 10: Responding to Payer Audits and Initiating Appeals (25 Minutes)

THE AUDITORS

• Who Conducts the Audit?

PRIVATE INSURERS

• Audits by Private Insurers
• The Health Care Fraud Prevention Partnership
• No Further Right to Appeal

BILLING PATTERNS

• Audit-Generating Conduct
• Data Mining and Analysis

RESPONDING TO A RECORDS REQUEST

• They Want My Records. Now What?

THE AUDITOR’S REPORT

• What to Expect from the Auditor’s Report

APPEALING MEDICARE’S DECISION

• The Medicare Appeal Process
• Level 1 Appeal
• Level 2 Appeal
• Level 3 Appeal
• Level 4 Appeal
• Level 5 Appeal

SETTLING WITH MEDICARE

• Medicare Consent Settlement Procedures

APPEALING MEDICAID’S DECISION

• The Medicaid Appeal Process

Speaker: Tizgel K.S. High

Module 11: How to Tell the Government It Gave You Too Much Money (30 Minutes)

OVERVIEW

• Voluntary Self-Disclosure

LEGAL DUTIES

• The Legal Duty to Report and Repay
• The Fraud Enforcement and Recovery Act of 2009
• The Affordable Care Act of 2010

THE TIMELINE

• Many Ways to Report and Return Overpayments
• The 60-Day Clock…When Does It Start Ticking?
• The Six-Year Lookback Period
• The Consequences of Being Late

VOLUNTARY DISCLOSURES

• The Strategic Benefits of Disclosure
• This Is Not a “Get Out of Jail Free” Card
• I’m Going to Self-Disclose. What are the Risks?
• I’m Going to Stay Quiet. What are the Risks?

WHO DO I TELL?

• The Medicare Administrative Contractor
• The OIG Provider Self-Disclosure Protocol
• CMS’ Self-Referral Disclosure Protocol
• Voluntary Disclosure to the Department of Justice

OTHER FACTORS

• Cooperation Credit

Speaker: Melissa A. Wong

Module 12: A Deeper Dive into Administrative Sanctions (25 Minutes)

OVERVIEW

• More Than Just a Slap on the Wrist

THE OIG’S SANCTION AUTHORITY

• Civil Monetary Penalties
• Exclusion from Federal Health Care Programs
• Mandator Exclusions
• Permissive Exclusions
• Procedural Due Process

CMS’ ENFORCEMENT TOOLS

• Medicare Payment Suspensions
• Medicaid Payment Suspensions
• Provider Enrollment Denials and Revocation

Speaker: Melissa A. Wong

Module 13: Prejudgment Remedies and Criminal Forfeiture (10 Minutes)

BEYOND ADMINISTRATIVE SANCTIONS

• Freezing Assets and Protecting Property
• The Fraud Injunction Statute
• The Anatomy of a § 1345 Lawsuit

THE COURTS

• What Can the Courts Do?

FORFEITURE OF PROPERTY

• Criminal Forfeiture for Federal Health Care Offenses

Speaker: Crane M. Pomerantz

Module 14: Criminal and Civil Settlements (25 Minutes)

LESSENING THE BLOW

• Giving the Government Exculpatory Evidence
• Making Your Case in a Position Statement

CRIMINAL CONVICTIONS

• Criminal Convictions: Individual vs. Corporation
• The Collateral Consequences of a Conviction

NEGOTIATING A PLEA

• The Criminal Plea Agreement

LET’S TALK ABOUT EXCLUSION, ONE LAST TIME

• Mandatory Exclusion
• Strategies That Might Help You Avoid Exclusion

DEFERRED PROSECUTION AGREEMENTS

• What’s a Deferred Prosecution Agreement?
• What’s in a DPA?
• Concerns About DPAs

GLOBAL RESOLUTION OF A FALSE CLAIMS ACT INVESTIGATION

• Settling with the Department of Justice
• The Corporate Integrity Agreement
• CIA Monitoring Options
• Potential Penalties Under a CIA

SETTLING WITH OTHERS

• Settling With a State
• When Whistleblowers Are Involved

Speaker: Crane M. Pomerantz