Risk management: Work with investigators

Monday, April 26, 2010

Q. A couple of my patients told me they have been interviewed by federal investigators. What’s up?

A. You’re being investigated and CMS and/or the FBI are laying the groundwork for a lawsuit. While claims disputes are usually handled by the DME MACs, CMS and the FBI will conduct field investigations if your company is suspected of fraudulent activity. It’s possible to hit the federal radar when you have been reported by a perceived credible source and the DME MAC or other CMS contractor has evaluated your claims history and determined you have an inordinate number of claims errors.

Federal investigators will approach patients first, then employees, under the guise of a friendly visit (usually at their homes after work hours) and they will be encouraged to not mention the visit to those under investigation. Referral sources such as doctors and discharge planners may also be interviewed. The target of the investigation is usually the last one interviewed and the investigators will more than likely show up at the office unannounced. No one is obligated to speak to an investigator. A person could be subpoenaed to talk with the investigator, but the option of retaining legal counsel is always available.

If you are the target of an investigation, attempt to understand what the charges are (or likely will be). To my surprise, federal investigators can have a wrong understanding of issues and yet still indict you. For example, one of the things I was indicted for was “unbundling of services.” The investigators erroneously believed that submitting a claim for a wheelchair and its accessories was “unbundling,” which it is not. And yet, I was indicted on that charge.

It may be possible to diffuse or minimize the effects of an investigation if you can work with the investigators. After their work is done, their investigation goes to a federal prosecutor, who will probably be less interested in your explanations.

Frank Margulis is president of Margin Consultants LLC. Reach him at www.MarginConsultants.com.