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Services - 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.

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 specializes in professional consulting services and has a team of highly skilled subject matter experts with substantial backgrounds in:

* Healthcare Compliance: Statistical Sampling, Medical Coding Audits, Healthcare Compliance Programs, Evaluation of Compliance Programs and Risk Assessments, HIPAA Compliance Risk Assessments & Training, Corporate Integrity Agreement (CIA) Board Advisor, Independent Review Organization (IRO) Services, Interim Healthcare Compliance Support, Physical Security Assessment, Design and Implementation of Sunshine Act Compliance Programs, Enterprise Risk Management Optimization, Governance, Risk and Compliance (GRC) System Support, Electronic Health Record (EHR) System Implementation, Outsourced Audit Function Support, Medical Risk Adjustment Compliance (Medicare, Medicaid, Commercial), Policy, Procedure, Internal Control Development and Evaluation, FedRAMP Compliance;

* Corporate Investigations: Fraud Investigations and Forensic Accounting, Anti-money Laundering (AML), Bank Secrecy Act (BSA), Know Your Customer (KYC), Foreign Corrupt Practices Act, Third-party Due Diligence;

* Corporate Compliance: Evaluation and Design of Corporate Compliance Programs, Interim Compliance Support, Compliance Risk Assessments, Physical Security Assessment, Enterprise Risk Management, Private Equity Governance, GRC System Support, Audit Function Support, Fraud Risk Assessments, Investigations Program Assessment and Enhancements, Qui Tam Investigations, Hot Line Support;

* Litigation Disputes: Complex Litigation and Disputes, Mergers and Acquisitions: Regulatory Due Diligence, Expert Witness, Statistical Analysis, Healthcare Payment Disputes, Litigation Support, Physical Security Assessment,  Neutral Party Data Analysis.

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