Audits, Subpoenas and Proactive Compliance: Avoid Legal Errors and Penalties

Format: On-Demand Webinar

Presenter: Eric Rubenstein, MSCJ, CFE

Duration: 60 minutes

Course Description:

Attendees will gain valuable insight into the various audits and investigations that are conducted in the government and commercial healthcare fraud, waste and abuse (FWA) space. The focus will be on government audits and investigations and the appropriate responses to such audits. Attendees will also gain an understanding of the different types of subpoenas that are available to law enforcement, and how understanding the subpoenas can help to shape an understanding of the issues presented.

Attendees will also learn about some of the most common proactive compliance measures available, and how to easily implement some of the Office of Inspector General’s recommended 7 points of a provider compliance program. Understanding the methodologies employed by the government to identify outlier claims can assist a healthcare provider in knowing where there may be lapses in compliance.

Learning Objectives:

• Learn about the various types of audits and investigations conducted by the government - CMS, MAC, UPIC, OIG, commercial payors
• Understand the value in knowing how subpoenas are issued, the types of subpoenas and the limitations of a subpoena
• Gain insight into knowing provider data from the inside as a proactive compliance measure
• Learn how to employ simple proactive measures to facilitate a culture of compliance and meet suggested compliance protocols as outlined by the OIG

Areas Covered in the Session:

• Audits vs. Investigations
  • UPIC/MAC/RAC/SIU
  • CERT/PERM
  • Difference between Audits and Investigation
• Reasons for Audits
  • Payment Integrity Purposes Check
  • Proper Enforcement of Payment Policies NCD/LCD
  • MUE/NCCI Circumventions
  • Error Rate Testing
  • Payment Error Rate Measurement (PERM)
  • Comprehensive Error Rate Testing (CERT)
  • Waste and Abuse
  • Empirical Study and Analysis
  • Office of Evaluation and Inspections (OEI)
  • Office of Audit Services (OAS)
  • Internal Purposes (Proactive for Compliance)
• PERM
• CERT
• Why are PERM and CERT Important
• Investigational Audits
• Subpoenas
• Criminal Subpoenas-Grand Jury
• Criminal-HIPAA
• Civil-CID
• Administrative-CMPL/OIG Subpoena
• Proactive Compliance is Key
• OIG Checklists as Guidance
• Report Overpayments and Determine Scope of Problem
• OIG Model Compliance Guidance

Suggested Attendees:

• Healthcare CEOs, CFOs, COOs
• Directors of Compliance
• Billing Managers
• Practice Managers
• Providers
• Compliance Professionals
• Compliance Attorneys 
• Billers, Coders and Auditors
• C-Suite
• Physicians
• Practice Managers
• In House Counsel
• Billing Companies
• Clinic Owners
• Chief Quality Officers
• Senior Internal Auditors
• Regulatory/Risk Officers
• Government Employees
• General Counsel   

About the Presenter:

Eric Rubenstein, MSCJ, CFE, is a seasoned retired federal law enforcement officer (25 years), specializing in white-collar crime investigations as a Special Agent for HHS-OIG. Wide-ranging experience involving federal healthcare programs, with an emphasis on crimes involving the Medicare and Medicaid programs by healthcare providers, including physicians, pharmacies and healthcare entities. Demonstrated success in complex criminal investigative management and planning. Over $500 million in restitution, forfeiture, damages, penalties and fines to government programs and over 150 convictions and civil settlements involving healthcare fraud matters. Broad trial experience, including three criminal trials in fourteen months (9 trials in all, including the first Civil False Claims Act trial in the District of New Jersey involving a violation of Stark). 20 years of presentation and training facilitation experience and a feature presenter/ trainer at local, regional and national training academies, conferences (such as the National Healthcare Fraud Association and the American Association of Professional Coders) and subject matter case analysis. Extensive mentoring and training of new agents. A conduit of information on internal and external policies and procedures for criminal, civil and administrative investigative matters.

A previous member of the IBM UCM project, providing Subject Matter Expertise on FWA matters as part of the Optimization Team servicing all UCM user groups (including UPICS, MEDIC and the greater UCM user community-law enforcement). A former Partner Liaison of the Trusted-Third Party for the Healthcare Fraud Prevention Partnership (HFPP) serving the membership of the HFPP and providing SME in the areas of FWA and investigative efforts to combat FWA in healthcare.

Assist/ consult with law firms and providers on due diligence, statistical sampling, self-disclosures, subpoena response, and OIG compliance-related issues, trial and litigation support. Subject Matter Expert (SME) in a variety of healthcare FWA issues, and previously retained as such for litigation and report preparation purposes.  

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