Proactive OIG Compliance: HHS-OIG Investigative Lifecycle 2023


Format: On-Demand Webinar
Duration of the training: 60 Minutes
Location: Online Webinar
By: Eric Rubenstein, MSCJ, CFE

This presentation will discuss the investigative and operational considerations that are undertaken by the OIG as part of the lifecycle of a criminal, civil or administrative investigation. This will segue into the importance of data analytics and the need for a robust compliance program that relies upon external audits and reviews.

Learning Objective:
  • Attendees will understand OIG case origins
  • Attendees will learn the difference between proactive and reactive investigations
  • Attendees will be able to understand how OIG cases are initiated
  • Attendees will learn about the importance of data analytics in both identifying investigations and proactive compliance
  • Attendees will be able to identify key concepts needed to be implemented to ensure that a quality proactive compliance program is in place
  • Attendees will understand how to interact with law enforcement in various settings
Areas Covered in the Session:
  • Initiation of an OIG investigation
    • Where are cases derived
    • OIG investigative considerations
    • Role of UPICS/MEDIC/MAC
  • Lifecycle Of An Investigation
  • Suggested Areas To Target For Compliance
  • Case Origins
    • Sources Of Complaints Can Be Both Reactive And Proactive
    • Relators (Whistleblowers)
  • A Hotline Complaint
  • OIG Heavy Reliance On Data Analytics-A/B And MA Enrollment
  • Part D Enrollment
  • Trends In Provider Billings
  • Trends In Specialties
  • Trends In Prescribing
  • OEI/OAS studies
  • OIG Workplan
  • How Data Can Support An Allegation
  • OIG Investigative Lifecycle
  • OIG Considerations
    • What Is The Estimated Loss Amount
    • What Are Office/Agency Priorities
    • What Is The Origin Of The Complaint
    • Is There A Patient Harm Issue
    • What Is The US Attorney’s Office Priority
  • The Alphabet Soup Of Medicare Contractors-Roles
    • UPIC (Parts A, B-including DME)-5 Regions
    • MEDIC- Part C and D
    • MAC
  • Investigative Lifecycle
  • Compliance Considerations-Law Enforcement
  • Other Compliance Considerations
  • OIG Model Compliance Guidance
Suggested Attendees:
  • Compliance Officers
  • C-Suite
  • Billers, coders and auditors
  • Healthcare CEOs, CFOs, COOs
  • Office Managers
  • Billing Staff
  • Physicians
  • Medical Auditors
  • Practice Managers
  • Auditors
  • In House Counsel
  • Billing Companies
  • Clinic Owners
  • Compliance Officers
  • Chief Quality Officers
  • Senior Internal Auditors
  • Directors of Compliance
  • Regulatory/Risk Officers
  • Government Employees
  • General Counsel
  • Compliance Attorneys
Presenter Biography:

Eric Rubenstein, MSCJ, CFE, is a seasoned retired federal law enforcement officer (25 years), specializing in white-collar crime investigations as a Special Agent for HHS-OIG. Wide-ranging experience involving federal healthcare programs, with an emphasis on crimes involving the Medicare and Medicaid programs by healthcare providers, including physicians, pharmacies and healthcare entities. Demonstrated success in complex criminal investigative management and planning. Over $500 million in restitution, forfeiture, damages, penalties and fines to government programs and over 150 convictions and civil settlements involving healthcare fraud matters. Broad trial experience, including three criminal trials in fourteen months (9 trials in all, including the first Civil False Claims Act trial in the District of New Jersey involving a violation of Stark). 20 years of presentation and training facilitation experience and a feature presenter/trainer at local, regional and national training academies, conferences (such as the National Healthcare Fraud Association and the American Association of Professional Coders) and subject matter case analysis. Extensive mentoring and training of new agents. A conduit of information on internal and external policies and procedures for criminal, civil and administrative investigative matters.

A previous member of the IBM UCM project, providing Subject Matter Expertise on FWA matters as part of the Optimization Team servicing all UCM user groups (including UPICS, MEDIC and the greater UCM user community-law enforcement). A former Partner Liaison of the Trusted-Third Party for the Healthcare Fraud Prevention Partnership (HFPP) serving the membership of the HFPP and providing SME in the areas of FWA and investigative efforts to combat FWA in healthcare.

Assist/consult with law firms and providers on due diligence, statistical sampling, self-disclosures, subpoena response, and OIG compliance-related issues, trial and litigation support. Subject Matter Expert (SME) in a variety of healthcare FWA issues, and previously retained as such for litigation and report preparation purposes.