On July 18, 2005, the regulatory world changed for all providers who participate in Medicaid and Medicare. That date marked the first day of a weeklong series in the New York Times highlighting fraud, waste, and abuse in both programs, particularly Medicaid. Due in large part to this series, lawmakers at Federal, State, and local levels across the country have given health care prosecutors and regulators their marching orders:

Investigate, prosecute, and substantially increase recoveries from providers.

This pressure on regulators and prosecutors intensified beginning in 2007. The reasons for this are simple: The amount of public money spent on Medicare and Medicaid is enormous and growing, and the prevailing opinion among lawmakers at all levels, and by regulatory agencies charged with safeguarding these programs, is that vast sums are lost each year to fraud, waste, abuse, billing error, and poor quality of care. The bottom line is that routine compliance programs no longer provide adequate protection against much more intensive enforcement initiatives dedicated to recovering funds.

• Effective January 1, 2007, Section 6032 of the Federal Deficit Reduction Act of 2005 mandated that all health care providers who receive $5 million or more of Medicaid funding must have an effective compliance program in place.
  
  
• Federal and State health care regulators and prosecutors across the country have significantly increased their staffs committed to drastically reduce fraud, waste, abuse and poor quality of care.
  
  
• In 2007, The Centers for Medicare & Medicaid Services (CMS) instituted unprecedented enforcement and investigative initiatives on a nationwide scale to dramatically increase recoveries lost to fraud, waste, abuse, and payment errors from providers of all services.
  
  
• Many states (such as New York and California) are now armed with False Claims Acts (FCAs), modeled on the Federal FCA, that are designed specifically to increase recoveries and insure strict compliance. These acts contain both Qui Tam, or whistleblower provisions, and severe penalties for violations of the FCAs.
  
  
• Federal and State agencies are working collaboratively with healthcare regulatory agencies to specifically address compliance issues in the areas of clinical trials, and research grant compliance.
  
  
• Substantially greater sanctions and monetary penalties may be imposed against providers that fail to comply with regulatory requirements addressing quality of patient care. Sanctions may range from monetary penalties to exclusion from federal and state healthcare programs and even incarceration for the most serious offenses.

This nationwide aggressive enforcement environment in the healthcare industry will continue indefinitely requiring that providers pay meticulous attention to their compliance programs and seek out litigation support tailored to complex healthcare investigations and prosecutions.

Daylight’s health care compliance unit was created specifically to help our clients to address their increased compliance obligations in this time of heightened regulatory enforcement. Our experience has shown that compliance programs need to adapt to current and prospective regulations. A program that was previously been deemed “effective” can easily develop deficiencies over a short period of time due to inevitable internal changes and shifting regulatory priorities.

We have monitored regulatory and enforcement developments carefully and have assembled a unique, multi-discliplinary team to assist and manage the complex challenges that arise from healthcare regulatory matters, investigations, and litigation. Most importantly, our team can make all the necessary adaptations to the program that will inevitably be needed.

We have devoted considerable time and resources to this highly active area of enforcement and count among our professionals former Assistant U.S. Attorneys who specialized in health care prosecutions, nationally-renowned compliance experts, prosecutors from Medicaid Fraud Control Units, former members of the FBI, and the OIG to assist our clients. Daylight professionals have comprehensive experience in managing every facet of health care compliance in this highly regulated industry. Our health care practice also includes an experienced staff of forensic auditors, deep resources of discipline-specific healthcare peer reviewers, certified coding specialists, and statisticians specializing in health care analysis.

Our team understands the dynamics of a health care investigation, the factors that both initiate it and those that continue to drive it once it has begun.

• Development of effective and comprehensive compliance programs specific to the provider type in accordance with applicable Federal and State laws and regulations.
  
  
• Designing and implementing policies and procedures tailored to the specific needs of the institution, and in accordance with all prevailing requirements by CMS, HHS, the Federal Sentencing Guidelines, and all state regulatory agencies.
  
  
• Conducting risk assessments or diagnostic studies to identify high risk areas of potential exposure and compliance deficiencies.
  
  
• Develop and Conduct specific compliance training procedures.
  
  
• Testing and Monitoring the effectiveness of an existing compliance plan, including claim submission processes, education and training, and applicable standards of conduct.
  
  
• Conducting internal compliance investigations, determine findings and making corrective recommendations.
  
  
• Coding review by expert certified coding specialists.
  
  
• Auditing and analyzing medical records and claims.
  
  
• Performing statistically-based data mining and billing database analyses.
  
  
• Cost report analysis.
  
  
• Serving as an Independent Review Organization under the terms of a Corporate Integrity Agreement.