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“Houston, We Have a Problem…”

Discover essential steps for healthcare providers facing billing errors and government investigations. This guide outlines a systematic approach to identifying issues, conducting internal investigations, and communicating with legal counsel. Learn how to report overpayments, understand compliance mandates, and minimize risk through effective corporate compliance plans. With actionable strategies for managing external audits, patient complaints, and internal reviews, this resource is designed to empower providers in navigating complex regulatory environments while maintaining integrity and accountability.

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“Houston, We Have a Problem…”

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  1. “Houston, We Have a Problem…” Responding to Billing Mistakes and Government Investigations

  2. Protecting your Providers

  3. “Houston, We Have a Problem” • Step One: Panic • Step Two: Breathe • Step Three: Follow the Plan

  4. Self Discovery of a Billing or Coding Issue • How is an issue discovered? • corporate compliance review • internal audit • external audit • patient complaint • employee complaint • competitor complaint • water cooler, elevator and cafeteria

  5. Identifying the Issue • Initial assessment of scope and severity • coding error (systems issue) • one or more providers • willful or just ignorant • pattern of concern • past behavior • policy-based issue • one or more payors • federal health care programs

  6. Initial Internal Investigation • Compliance office and/or compliance committee • Identifying issues where outside counsel should be leading the investigation • Containment plan • any immediate action required • ongoing/future behavior changes • risk management needs

  7. Outside Counsel – Internal Investigation

  8. Outside Counsel • Internal lines of authority and communication • Attorney-client privilege • Leading the investigation • Investigation plan • Report/plan to the Board and/or Compliance Committee • Litigation hold • Document review • Witness interviews • Risk assessment • Action plan recommendations • Policy/procedure development

  9. Timing of Investigation Overpayments Must be reported & returned within 60 days of the date identified or the date when the corresponding cost report is due, whichever is later Has there been an Overpayment?

  10. False Claim Act - Risks Knowingly conceals or improperly avoids an obligation to pay money

  11. Refunds and Repayments to the Carrier • When to Report • When is overpayment identified • What to Report and Refund • How far back in time? • Each claim? • Extrapolation? • Refund • Carrier requirements • Self Disclosure • Risk Analysis

  12. The Mission of the OIG To protect the integrity of HHS programs and operations and the wellbeing of beneficiaries by: * detecting and preventing fraud, waste, and abuse; * identifying opportunities to improve program economy, efficiency, and effectiveness; and * holding accountable those who do not meet program requirements or who violate Federal laws.

  13. Target of the Investigation • Step One: Panic • Step Two: Breathe • Step Three: Follow the Plan

  14. What is the Plan? • Corporate Compliance Plan should include response to on-site investigators • Train staff and managers how to respond • Scripting • Response Team Notification • Administration • Legal Counsel • Legal counsel action plan

  15. Legal Counsel Action Plan • Establishing rapport with investigators • Promoting a spirit of cooperation • Notice and planning with administration • Litigation holds • Establishing lines of authority • Internal investigation scope • Same issues • Related issues • Rumors • Conducting internal investigation • Documents • Witnesses • Experts

  16. Working with the Department of Justice • Attitude, attitude, attitude • Educating the government • Clinical issues • Operational issues • Providing documents • Providing witnesses • Providing position statements • Settlement options

  17. Responding to Requests for Discovery • Informal requests • Witness interviews • Civil Investigative Demand • Subpoenas • Peer Review Protections • Letters of Assurance

  18. Additional Risks and Items for Consideration • Criminal behavior? • Obstruction of justice? • Medical malpractice claims? • Fiduciary duties? • Public relations • Press release • Insurance coverage

  19. Discussion and questions

  20. Laura D. Seng, RN, JD, PartnerBarnes & Thornburg LLP100 North Michigan, Suite 700South Bend, Indiana 46601(574) 237-1129Laura.Seng@btlaw.com

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