A multi-state healthcare operator receives a whistleblower complaint (via hotline) alleging upcoding of patient care services and billing for unnecessary medical services across several facilities. The complaint references prior internal emails sent to a former compliance officer which included attachments suggesting pressure on staff to maximize reimbursement. A preliminary review estimates potential exposure of several million dollars over a two-year period. The company has expanded through acquisitions in recent years, which has resulted in varying billing controls and documentation practices across locations.

Discussion themes:

• Defining investigation scope, timing, governance
• Addressing preservation challenges across decentralized facilities/legacy systems
• Coordinating with key stakeholders from legal, compliance, finance/accounting
• Managing financial reporting and auditor engagement
• Developing internal and external communications strategy
• Evaluating self-disclosure timing and strategy with DOJ and HHS-OIG
• Assessing potential civil, criminal, financial, and remediation exposure