Amanda S. Marshall Former U.S. Attorney (Local Counsel)
Lynette Byrd Former Assistant U.S. Attorney
Roger Bach Former Special Agent (OIG & DEA)
Joe Brown Former U.S. Attorney
Qlarant Investigations and Audits
Qlarant Integrity Solutions is a Maryland-based private contractor that conducts Medicare and Medicaid fraud investigations and audits on behalf of the Centers for Medicare and Medicaid Services (CMS). While investigations and audits conducted by Qlarant often result in substantial recoupments and other penalties, in our experience many allegations of “fraud, waste, and abuse” are misguided.
In 2018, the Centers for Medicare and Medicaid Services (CMS) selected Qlarant Integrity Solutions (“Qlarant”) as its Investigations Medicare Drug Integrity Contractor (I-MEDIC) to conduct fraud investigations and audits related to Medicare Parts C and D, and also selected Qlarant as one of several Unified Program Integrity Contractors (UPICs) to conduct fraud investigations and audits related to all other Medicare and Medicaid programs.
What is Qlarant?
In press releases announcing these appointments (here and here), Qlarant describes itself as, “a not-for-profit nationally respected leader in fighting fraud, waste [and] abuse, improving program quality, and optimizing performance.” The press releases go on to state, “The company uses subject matter experts and innovative data sciences and technology to help organizations see risks, solve problems, and seize opportunities.” On its website, Qlarant writes:
“The Qlarant investigation team consists of former federal law enforcement officers experienced in investigative techniques that successfully uncover fraud, waste, and abuse for prosecution. We’re unmatched in experience, investigation and predictive modeling, staying ahead of the industry and ahead of bad actors.
“Our expertise comes from fifteen years of on-the-ground experience in investigation.
“With our expertise in law enforcement, our team can actively and authoritatively document and present cases, with case summaries, written reports, and referral pages for cases provided to law enforcement for criminal or civil action.”
As CMS’s I-MEDIC for Medicare Parts C and D, Qlarant conducts investigations and audits nationwide. In its capacity as a UPIC, Qlarant has been granted the authority to conduct Medicare and Medicaid investigations and audits in the following jurisdictions:
What Should Healthcare Providers Expect During Qlarant Audits and Investigations?
Although all CMS contractors are supposed to uncover both overpayments and underpayments, Qlarant’s marketing materials make clear that it has a singular goal: to help CMS recover as much money as possible from program-participating healthcare providers. While Qlarant relies heavily on software that automatically scans Medicare and Medicaid billing data for apparent “outliers,” it also deploys “Jump Teams” that conduct “boots-on-the-ground” investigations targeting “the worst potential offenders.” As a practical matter, there is little, if any, distinction between investigations and audits, as both have the potential to result in substantial penalties and referral to the U.S. Department of Justice (DOJ) for civil or criminal prosecution.
Common Allegations in Qlarant Investigations and Audits
Qlarant investigations and audits can focus on two primary types of healthcare fraud: (i) Medicare and Medicaid billing violations, and (ii) unlawful financial relationships between program-participating providers.
Investigations and audits focused on billing violations examine providers’ Medicare and Medicaid data to identify issues such as billing for medically-unnecessary services and supplies, performing unnecessary tests and examinations, providing prescriptions for unnecessary medications and durable medical equipment (DME), unbundling, upcoding, double-billing, and other intentional and unintentional coding mistakes. Investigations and audits focused on providers’ financial relationships seek to expose unlawful referral fees and other violations of the Anti-Kickback Statute and Stark Law. Both types of allegations carry the potential for severe penalties including recoupments, fines, denial of pending claims, prepayment review of future claims, program exclusion, and even federal imprisonment.
Determining the Nature of the Allegations Against You
When facing a Qlarant investigation or audit, a key preliminary step is to determine the nature of the allegations against your business or practice: Are you being accused of overbilling Medicare or Medicaid? Are you being accused of unlawfully using Medicare or Medicaid funds to pay for beneficiary referrals? Are you being accused of both? Once you know what is being investigated, then you can build the best defense strategy that is tailored to the particular circumstances at hand.
Although Qlarant’s investigators or auditors are unlikely to tell you precisely what they are looking for, there are a few ways to determine why the company has chosen to target your business or practice. These include:
Prompt Intervention in the Investigation or Audit – If you hire the best lawyers who are experienced in Medicare and Medicaid fraud defense, your defense team should be able to promptly intervene in the investigation or audit and determine why Qlarant is demanding to see your company’s records.
Analysis of the Records Being Requested – The types of records Qlarant requests during the investigation or audit can also provide insight into the focus of the inquiry. If Qlarant is solely requesting records related to billings and patient services, the inquiry is most likely targeting billing and coding fraud. If Qlarant is requesting copies of agreements and the names of other providers you work with, then you may be facing an illegal “kickback” investigation.
Internal Audit and Risk Assessment – You can also gain insight into what Qlarant’s investigators or auditors may be looking for by conducting an internal audit and risk assessment. In fact, if your business or practice has improperly billed the federal government or engaged in unlawful transactions, you need to get control of the issue before Qlarant finds information it can use against you.
What Can Healthcare Providers Do to Protect Themselves During Qlarant Investigations and Audits?
If your healthcare business or medical practice is facing a Qlarant audit or investigation, you must devote the time and resources necessary to prevent an unfavorable and unjust result. While Qlarant and CMS’s other fee-for-service audit contractors play an important role in preventing fraud, waste, and abuse in the Medicare and Medicaid systems, in our experience they routinely make mistakes that result in unwarranted recoupment demands and other penalties. Furthermore, since CMS audit contractors arerequired to refer providers to the DOJ when they uncover alleged unlawful activity, misguided audit determinations can have severe consequences that extend far beyond the initial audit determination.
As a result, if you have been contacted by Qlarant, there are some steps you should try to take right away. These steps include (but are not limited to):
Carefully review Qlarant’s request for documents, but do not provide anything yet. Carefully review Qlarant’s request for documents to, and note the deadline to respond. But, do not provide any documents to Qlarant until you speak with the best healthcare defense attorney.
Preserve all records that are potentially relevant to the investigation or audit. Ensure that all records that are potentially relevant to the investigation or audit are preserved. This includes interrupting regularly scheduled purges and overwrites of electronically stored information.
Avoid speaking with Qlarant’s investigators or auditors directly. Due to the risks involved in Medicare and Medicaid investigations and audits, you should avoid discussing any substantive matters with Qlarant directly. Instead, you should have your attorney deal with the investigators or auditors on your behalf.
Determine whether you have any self-disclosure obligations. If your business or practice has overbilled Medicare or Medicaid, you may have an obligation to self-disclose any overpayments to CMS. You must determine if you have any self-disclosure obligations before Qlarant makes a determination of liability.
Execute a targeted and strategic defense. In order to avoid costly consequences, you must execute a targeted and strategic defense. Your defense should challenge Qlarant’s methods and assumptions from all angles, and it should be focused on preventing an unfavorable outcome that results in a referral to the DOJ.
Put our highly experienced team on your side
Dr. Nick Oberheiden
John W. Sellers
Former Senior Trial Attorney U.S. Department of Justice
Joanne Fine DeLena
Former Assistant U.S. Attorney
Lynette S. Byrd
Former Assistant U.S. Attorney
Former U.S. Attorney
Aaron L. Wiley
Former Federal Prosecutor
Former Special Agent (OIG)
Former Supervisory Special Agent (FBI)
Former Special Agent (FBI & IRS-CI)
Kevin M. Sheridan
Former Special Agent (FBI)
Former Supervisory Special Agent (FBI)
Dennis A. Wichern
Former Special Agent-in-Charge (DEA)
Why Do Healthcare Providers Nationwide Choose Oberheiden, P.C.?
Our firm represents physicians, pharmacists, medical practices, clinics, laboratories, hospitals, durable medical equipment (DME) distributors, and other healthcare clients across the country. Our attorneys are highly experienced in healthcare fraud matters, including experience as former DOJ attorneys and healthcare fraud prosecutors with the U.S. Attorney’s office. At Oberheiden, P.C., we offer:
One firm, nationwide defense. We have successfully represented healthcare providers in 48 states, and we have strategic office locations around the country to effectively serve our clients.
Direct lines to our senior attorneys. All clients work directly with our senior attorneys (we do not employ paralegals and junior associates), and our clients have access to our attorneys 24/7.
Custom-tailored defense strategies. As a result of our extensive experience on both sides of Medicare and Medicaid cases, we are able to develop custom-tailored defense strategies focused on the specific factual and legal issues at hand.
Relentless pursuit of success. We relentless pursue success on behalf of our clients, working tirelessly to protect them to the fullest extent possible.
Speak with a Qlarant Audit Defense Attorney at Oberheiden P.C.
Have you been contacted by Qlarant? If so, we encourage you to contact us immediately for a free and confidential consultation. To speak with a healthcare fraud defense lawyer at Oberheiden, P.C., call 888-680-1745 or tell us how we can help online now.
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