Health Care Fraud Investigation and Litigation Support
Our fraud investigation and litigation support clients include state and federal entities ranging from state program integrity/office of inspector general units (OIG), the FBI, and Medicaid fraud control units (MFCUs) to the United States Department of Justice (DOJ). We completely understand the confidential nature of governmental investigations and have numerous individuals on our team with security clearances. Our litigation support team includes health care staff who can provide both consulting and expert witness services as needed.
Myers and Stauffer specializes in bringing the case together. We examine the case file and assist in developing a strategy to prepare the investigative team for trial; and, if necessary, settlement options relating to the case. We often participate in witness interviews, provide support for financial calculations, explain the case to the entity being investigated, assist in settlement negotiations, and review settlement agreements.
Our litigation support services include the following:
Financial Reviews. We provide forensic accounting, damage calculations, and fair market evaluation opinions. Our accountants and analysts provide a variety of litigation consulting services related to tracing fraud proceeds to money laundering companies; identifying assets derived directly or indirectly from fraud proceeds and assisting with asset forfeiture; calculating lowest intermediary balance analysis; identifying overseas transactions; providing calculation of damages; providing expert fair market value and commercial reasonableness of healthcare relationship evaluations; and preparing summary trial exhibits.
Claims Reviews. Myers and Stauffer has experience not only working with Medicare, Medicaid, and Tricare claims, but also state Medicaid/Children’s Health Insurance Program fee-for-service, managed care encounter claims, Prescription Drug Monitoring Program (PDMP) data, and private insurance claims data. We have been instrumental in assisting agencies with large-scale investigations where multiple government and private payors are involved. We provide a variety of data analysis to assist the investigation or audit.
Compliance Reviews. Myers and Stauffer can help identify fraudulent activity from provider compliance reviews. These reviews verify compliance with non-clinical regulatory and policy requirements.
Clinical Coding Reviews. Myers and Stauffer has physicians, nurses, dental consultants, pharmacists, and certified claims coders with a broad range of clinical and coding experience. Our professionals are not simply experts in their clinical fields, they also have the post-payment review and expert witness experience to successfully close cases, achieving a significant return on your investment, and providing the case support you need.
Data Analytics. Myers and Stauffer creates and refines various algorithms designed to analyze claims and determine whether payments were made in accordance with Medicaid, Medicare, managed care, or other government payor policies. Correct coding initiatives and clinical team knowledge is translated to Structured Query Language logic, allowing analysts to programmatically target areas of concern. Myers and Stauffer has also designed and executed statistical sampling plans to extrapolate overpayment findings across defined strata.
Managed Care Experience. Through our managed care experience, we understand the issues and concerns that present the greatest amount of risk to Medicaid and Medicare managed care programs. Our experience can help your agency understand and navigate the added complexities that occur when cases involve managed care.
Programmatic and Policy Expertise. We can assist agencies in researching, understanding, and interpreting Medicaid, Medicare, managed care, and other government payor policies, and offer a better understanding of increasingly complex payment and health care delivery models. Alternative payment models and innovative health care delivery systems are changing the health care landscape. We have been at the forefront of these initiatives and have expert knowledge of how these are designed and operated.
Expert Witness Testimony and General Case Preparation. Myers and Stauffer can help examine case files and assist in developing strategies to prepare investigative teams for settlement options and, if necessary, trials relating to cases. We often participate in witness interviews, provide support for financial calculations, assist in settlement negotiations, review settlement agreements, and testify and prepare expert reports based on our findings.
Qualifications and Experience
Our experience providing assurance and consulting services to state Medicaid programs, Medicare, the U.S. Department of Justice (DOJ), and other government health care and human service agencies is unrivaled. We offer a full array of services designed to assist our state and federal clients with success in every part of their benefit programs. A sample of our services includes:
- Forensic accounting.
- Asset tracing.
- Medicare, Medicaid, and third party claims knowledge.
- Policy and procedure analysis.
- Development of financial models.
- Analysis of proposed legislation.
- Calculation of performance measures, benchmarks, and improvement target goals.
- Contract and/or vendor compliance reviews.
- Medicaid funding consulting including provider assessment plans.
- Compliance reviews.
- Cost report audits and settlements.
- Financial and performance audits of Medicare and Medicaid managed care organizations (MCOs).
- Reimbursement methodology design and implementation.
- Calculation of damages.
- Stark Law expertise.
- Establishment of provider reimbursement rates.
- Appeal representation and expert witness testimony.
- Fraud, waste, and abuse detection and identification of improper payments through claim/billing reviews.
- Pharmacy claims and pharmacy benefit manager (PBM)audits.
- Medicaid performance audits and consulting engagements.
- Representation of states before Centers for Medicare and Medicaid Services (CMS), DOJ, and Office of Inspector General (OIG).
- Assistance with CMS and OIG audit findings.