Career Highlights
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- Registered Nurse (40+ years)
- Presented FWA investigation findings at CMS conference
- Testified as Expert Witness in both Civil and Criminal Court Cases
- Established the Medicare Advantage Part C FWA review process for the MEDIC
- Certified Professional Coder (CPC)
- Certified Risk Adjustment Coder (CRC)
- Advanced HCC Auditor (AHCCA)
- HealthCare Anti-Fraud Associate (HCAFA)
- Certified Clinical Documentation Specialist for Outpatient (CCDS-O)
Lorraine is a Registered Nurse and holds certification as a Certified Professional Coder (CPC), Certified Risk Adjustment Coder (CRC) from the American Academy of Professional Coders (AAPC), and Advanced HCC Auditor (AHCCA) from Rise Health. She is also certified as a HealthCare Anti-Fraud Associate (HCAFA), Certified Clinical Documentation Specialist for Outpatient (CCDS-O), and is currently SunHawk Consulting’s Clinical Coding Audit Director.
Lorraine has been a coding trainer and reviewer for one of the largest U.S. healthcare organizations. Within regulatory organizations, she has worked with state Medicaid policy and program integrity, MFCUs, RACs, MEDIC, and was a corporate clinical trainer for a national vendor who assisted Medicare and Medicaid Advantage companies with risk adjustment data collection, coding and reporting. She has provided testimony and expert analysis for both government prosecutors, litigation counsel, and defense counsel.
Select Engagement Experience
Review of Claims for a Large Dental Organization
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.
Behavioral Health Organization Evaluation for a 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.
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. Lorraine’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.
Testimonials
"SunHawk demonstrated a commendable commitment to precision and compliance throughout our engagement. Their expertise in navigating complex healthcare regulations was evident, providing us with a thorough and insightful audit. We required assistance with a complex billing audit that required statistical analysis. As a smaller healthcare system, SunHawk provided us a level of audit expertise that we are not able to staff in-house. The team’s responsiveness and industry knowledge make them a valuable partner for healthcare organizations seeking rigorous and reliable auditing services."
Sara Coverstone
Chief Compliance & Privacy Officer
Northern Arizona Healthcare
"SunHawk was an outstanding partner in the provision of interim leadership in compliance and internal audit for our organization. They provided seamless coverage and advancement of our compliance and internal audit functions. As CEO, I had no concerns or worries during our engagement. They were true partners for us!"
Alfred E. Pilong
President and CEO
Garnet Health
"James and the SunHawk team have been an invaluable resource for our Compliance Office - they are a reliable, well experienced, trusted and knowledgeable team of professionals who at a moment’s notice will take your calls or respond to your emails.
Their advice helped us navigate the ever evolving, highly regulated healthcare industry! Whether it’s discussing report methodology or determining appropriate repayment, SunHawk provides the reassurance and confidence that you are doing the right thing!
We are honored to have partnered with SunHawk and will continue to do so in the future!"
Natasha Cogdill
Vice President/Chief Ethics, Compliance and Privacy Officer
Community Health System
"SunHawk’s professionals are leaders in the compliance and risk industries. Over the years I have worked with a number of their professionals on a series of projects/issues and learned SunHawk’s professionals are problem/solution-oriented and great coalition builders.
SunHawk Professionals get the job done and are a pleasure to work with. Commitment, Experience, Professionalism, and Integrity; that's what SunHawk Professionals brings to the table."
Gerry Roy
Vice President/Chief Ethics, Compliance and Privacy Officer
Phoenix Children's Hospital
"Jim Rough is among the most conscientious professionals I have encountered. When he says he is going to do something -- he does it. Jim has a broad range of experience gained over decades in leading organizations.
Now as the founder of his own firm, Jim will be enabled to provide the same high-quality service to his clients in a setting that allows greater customization to his clients' financial circumstances."
Frank M. Placenti
Chair, US Corporate Governance & Securities Regulation
Practice, Squire Patton Boggs
"SunHawk Consulting's HIPAA Check Program provided us with an invaluable third-party review of our HIPAA policies and practices. The tracking tool SunHawk includes with the Program has become an integral part of our continued monitoring for HIPAA compliance.
Jan Elezian's extensive hands-on compliance experience was evident during site visits and staff interviews as she translated difficult subject matter into practical use scenarios and provided quality feedback. Thank you SunHawk team!"
Nancy Lipman
Vice President, Compliance
Chicanos Por La Causa, Inc.
"SunHawk provides an array of dynamic professionals, each with significant subject matter expertise and a problem-solver approach. Beyond their knowledge and conscientious work ethic, however, is a team of caring individuals who strive to furnish individualized, tailored assistance with a personal touch.
Jim Rough's dedication to the success of SunHawk clients is evidenced by his strategic and prospective thinking complemented by his ability to truly anticipate the needs of a company in the midst of the complicated compliance climate. I highly recommend SunHawk for companies of any size seeking actionable solutions and measurable results."
Michelle Missal
Vice President and Chief Compliance Officer
Paragon 28, Inc.
“Sunhawk Consulting has proven to be a trusted partner with the ability to deliver results. We have consistently been impressed with their expertise, professionalism, and commitment to customer service. Sunhawk Consulting has supported our enterprise-wide risk assessment, risk management activities, and the configuration of our Governance, Risk and Compliance software tool.
Sunhawk Consulting’s leadership and consultative services have helped us to successfully navigate through the complexities of SOC, HIPAA, NIST and FedRAMP audits this year. The knowledgeable team of Sunhawk professionals has been and continues to be an invaluable resource for us, ensuring we are positioned for success in all our audits and assessment activities.”
Zachary Fain
Chief Technology Officer (CTO)
Signature Performance
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SunHawk Consulting
2550 E Rose Garden Ln.
Unit 72016
Phoenix, AZ 85050
info@sunhawkconsulting.com
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