Healthcare Compliance Case Studies
HIPAA Privacy Compliance Program Assessment for Multi-State DME and Sleep Lab Providers
SunHawk was engaged by one of the nation’s largest DME and Sleep Lab Provider to assess its HIPAA Compliance Programs. To accomplish this task, SunHawk evaluated the enterprise’s policies, vendor security, internal controls, and risks across 340+ Privacy, Security, and Breach Notification Standards. SunHawk identified risks and associated corrective actions to Management and provided an executive summary to the CEO and Board of Directors. By implementing the corrective actions, the organization was able to enhance its privacy program and protect the sensitive information of its clients.
Interim Compliance Officer for a Non-Profit Regional Health System
A SunHawk expert was hired to serve as interim Chief Compliance Officer for a non-profit regional health system, tasked with leading the IA and compliance departments. Responsibilities included assessing the HIPAA privacy and security program and supporting the search process for a permanent CCO. SunHawk's expert chaired the Compliance Committee, reported regularly to the CEO and Board Audit and Compliance Committee, providing updates on her work with senior leadership to improve RAC and third-party audit tracking, reviews, and responses. She also provided HIM training and support, evaluated the effectiveness of the enterprise’s compliance program for the Board, conducted compliance and privacy investigations, and worked with senior leadership to implement corrective action plans and monitoring. SunHawk's expertise and leadership were critical to the success of the organization during this transitional period, and her contributions were highly valued by the CEO and Board.
Quarterly Audit of Claims for a Multi-State Dental Practice
A large multi-practice dental organization engaged SunHawk to perform a random sample review of claims on a quarterly basis, ensuring that documentation and billing met requirements. Based on SunHawk's review, we provided recommendations for internal practice and medical documentation, aiming to clearly substantiate that procedures were performed. Over the year-long project, the practice group initiated several small yet significant changes, which led to a decrease in the frequency of coding errors and improvements in clear, supportive documentation.
Implementation of Sunshine Act Compliance Reporting Program for Medical Device Company
An international neuroscience company engaged SunHawk to fulfill the requirements of a U.S.-based federal transparency law overseen by the Centers for Medicare & Medicaid Services (CMS), commonly known as the Sunshine Act or Open Payments. With the CMS reporting deadline quickly approaching, SunHawk successfully completed a comprehensive current-state assessment and provided a right-sized solution. SunHawk also supported the company with expert advice on the legislative complexities and nuances of the act, along with practical tips for achieving compliance. Consequently, the company was able to submit its first report ahead of the deadline and was well-positioned to maintain compliance with the act moving forward.
Helped Behavioral Health Organization Implement New EHR System
SunHawk partnered with a large, multi-faceted behavioral health organization to evaluate their current procedures, documentation, and coding as they sought a new electronic health record (EHR) system. Through staff interviews, site visits, and facility tours, SunHawk identified limitations of the existing EHR system and understood the process flow from patient intake to discharge. They distinguished necessary tasks from desirable ones in a new EHR system, which helped to eliminate or reduce the current limitations. This led to a tailored requirement list for a new EHR system, which the entity presented to prospective vendors for a customized solution.
Compliance Project for Major Utilization Management Vendor
SunHawk was engaged by one of the nation’s largest utilization management vendors to prepare policies, procedures, and reporting templates designed to ensure proper Medical Loss Ratio reporting for Commercial, Medicare Advantage and States’ Medicaid programs, including testing of quality improvement initiative expenses.
Ensured Compliance with Clinical Criteria and Documentation Requirements of Hospital Claims Related to Protein-Calorie Malnutrition
SunHawk reviewed multi-hospital inpatient claims regarding severe protein-calorie malnutrition (PCM) diagnoses, ensuring compliance with American Society for Parenteral and Enteral Nutrition (ASPEN) criteria, and physician documentation. SunHawk's review, including coding team queries, reported on documentation quality and conflicts. Based on the findings, the hospital system re-educated providers including nutritionists and dieticians of the ASPEN criteria and documentation requirements for this diagnosis. SunHawk also suggested the hospital system develop a compliant-query template to be used for all queries related to this diagnosis.
Establishment of Clear Risk-Adjustment-Based Coding Policies, Practices and Procedures
SunHawk helped a health management company optimize their Risk Adjustment (RA) coding processes. They clarified ambiguous areas of diagnosis coding and defined risk levels suitable for the company's RA program. SunHawk's review and recommendations refined the company's policies and procedures aligning them with their mission, values, and risk level. This resulted in the development of clear policies, a comprehensive RA coding education program, and a quality assurance initiative for RA coding.
Medical Coding Audit and Clinical Documentation Improvement Related to Acquisition
SunHawk Consulting was entrusted by a multi-state population health management company to carry out a comprehensive audit of documentation for telehealth visits. This audit was necessitated as part of the strategic acquisition of a California-based health plan that was utilizing telehealth services for its members. Throughout the auditing process, SunHawk employed its expertise to unearth critical insights and identify necessary modifications to the existing documentation templates as clinical documentation improvements to ensure documentation supported all requirements of a telehealth visit.
Clinical Documentation Improvement and Medical Coding Audit on Annual Wellness Visits
SunHawk Consulting was hired by a multi-state population health management to carry out a comprehensive audit of medical record documentation of encounters which had been billed as a Medicare Annual Wellness Visit (AWV). This audit was necessitated as part of the strategic acquisition of a California-based health plan that was utilizing telehealth services for the AWV for its members. SunHawk identified missing and/or inadequate documentation, calculated the resulting Medicare overpayment, and formulated a comprehensive list of proposed changes for provider education and the existing documentation templates for clinical documentation improvement purposes.
Identity Theft Fraud Investigation
SunHawk led an investigation on behalf of a law firm and its employees who were victimized by identity theft. The investigation determined how the identity theft breach occurred, the extent of the breach, and the individuals involved. SunHawk performed dark web and deep web Internet scans that determined the stolen information came from major data breaches that occurred years earlier. The evidence developed was referred to federal law enforcement resulting in the arrests of members of the identity theft ring responsible for the breach of the law firm and other victims. As a result of the quick response and investigation results, the law firm suffered no financial loss and no further acts of identity theft have occurred.
Inventory Theft Investigation
SunHawk Consulting led an investigation on behalf of a transportation industry company involving the alleged misconduct of an employee in the theft of company-owned goods. The investigation confirmed the theft of inventory and that the subject of the investigation was a manager at the company. Knowing that his direct reports were being interviewed, this manager tried to persuade the employees not to cooperate with SunHawk’s investigators. The investigation also revealed that the manager was sexually harassing his employees and he was terminated. SunHawk also provided recommended enhancements to the company’s code of conduct and business ethics policy in furtherance of their corporate compliance program.
Internal Investigation on Behalf of General Counsel of Construction Company
SunHawk was engaged by the management of a national interior design and construction provider to investigate possible bribery and other ethics violations under the direction of General Counsel. The investigation team performed anemail review of approximately 700,000 emails and conducted twenty interviews over a two-month period. Besides providing a report of investigation findings, SunHawk recommended areas of program improvement to company management.
Litigation Disputes Case Studies
Usual and Customary Market Rates Expert Report Prepared For Healthcare Litigation Case
SunHawk was engaged by outside counsel of health insurers to testify in defense of lawsuits involving appropriate reimbursement for out-of-network providers under state regulations, contracts, and industry standards. In many cases, we use public Medicare reimbursement information and private commercial reimbursement datasets to determine Usual and Customary Market Rates (UCR). We were also asked to testify on usual claims management and payment practices of health insurers based on the facts of the case.
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