CRA Forensic Services professionals were retained to assist a multi-state hospice provider in assessing and responding to a government investigation into alleged violations of the False Claims Act and the Anti-Kickback Statute, including whistleblower allegations of medically unnecessary long stays, because certain patients were living longer than expected. The timing of the government’s scrutiny created additional business stress because the provider was amid endeavoring to sell itself, and the legal “overhang” was materially depressing its valuation.
Our Team’s actions:
- Analyzed probe sample of patient charts: we assessed compliance with Medicare documentation and certification eligibility standards, including data gleaned from the Relator’s Complaint, to review patient care holistically, analyzing trends across patients, providers, states, diagnosis codes, etc.
- Reverse-engineered government’s sampling methodology: we identified numerous flaws in the apparent statistical approach used by the government to design its sample population, allowing us to identify the government’s compliance focus and reveal more precisely other risk areas for further analysis.
- Performed risk assessment analytics: we conducted a thorough analysis of claims data and location-specific PEPPER reports to successfully identify both risk areas and opportunities for affirmative defense.
- Designed flexible damages model: we constructed a powerful damages model to inform potential defense strategies and support settlement discussions, incorporating our chart review findings, data analytics, and alternative care criteria.
Impact:
Our client successfully resolved its exposure for a de minimis amount and was able to proceed with the planned sale of the business at full value. The team was led by CRA Forensic Services Leader and Vice President Kristofer Swanson, with invaluable assistance from Patricia Peláez, Amanda Kight, and our team of highly credentialed healthcare clinicians and coders.
