Project Description

CMS billing practices expert for whistleblower’s false claims suit

The need

Attorneys representing the US government in a False Claims Act suit needed an expert that had previous experience with Centers for Medicare and Medicaid Services (CMS) to consult on the materiality of certain CMS billing practices by a home health agency (HHA). In this case, the HHA was accused of failing to provide the full number of visits and services in patient Plans of Care that the HHA had claimed to deliver and invoiced for payment. The HHA was also accused of misreporting service time meaning healthcare providers spent less time on home visits than reported.

Our approach

Knowing the details of the case it was clear that the expert would need to be able to review the agency’s records to understand the truth of what happened and whether the agency actually followed the Plans of Care that the doctors required, and actually provided the invoiced services. That knowledge in mind, we went to work quickly to find an expert with experience working with CMS as well as with healthcare insurance and compliance.

The expert

We found an expert that had over 35 years of experience in the healthcare insurance, managed care and compliance industries. In her long career, she had been a compliance officer for a large health insurance company as well as a compliance specialist at a CMS Medicare Program Safeguard Contractor. In addition to her vast compliance experience, she also had experience in internal investigations specifically related to compliance and whistleblower concerns. The suit was successfully resolved with a large settlement shared between the federal and state governments.