In-Depth Analysis Mitigates
Whistleblower Fallout
A resource for DNA testing, analysis, genetic diagnostics and consultation in New England comprised multiple entities: a nonprofit laboratory and the private practices of a number of physicians, all operating under the umbrella of an academic institution that provided infrastructure and staffing support. Day-to-day operations were commanded by the physician principals. 

Parallel lines of service get perilously tangled in billing.

While the nonprofit lab and the private physicians performed in a seamless, complimentary manner, critical regulatory distinctions appeared to have been overlooked in the billing process. The resulting irregularities drew the attention of an internal whistleblower, which prompted a high-level, independent financial audit and a decision to self-disclose irregularities to the OIG (Office of Inspector General). In order to preempt a crippling intervention and penalties, the principals and their legal and financial advisors agreed that a credible restitution offer was essential to their "mea culpa." 

Assessing irregularities ahead of the regulators... 

On a referral made by legal counsel, VantagePoint was engaged to analyze the extent of past irregularities so that a reasonable valuation could be assessed, and to advise staff on correct billing practices going forward. Conducting interviews and painstaking research into the records, the procedures involved and the applicable staffing, billing and coding regulations, VantagePoint brought to light evidence that the guidelines themselves were demonstrably unclear, and that managers, nonetheless, could be represented as having made a good faith effort to abide by them. These findings would ultimately serve to reasonably limit the restitution offer on behalf of the principals.  

...VantagePoint supplies the basis for a best-case outcome and coaches best practices for averting future crises. 

The detailed, authoritative work conducted by VantagePoint has served to support negotiations and good prospects for a resolution with the OIG. At the same time, VantagePoint has provided education, training and support to staff members, ensuring that compliant coding and billing processes are applied appropriately in the future for both laboratory procedures and physician services.

Billing and coding rules are often vague and difficult to interpret. Our deep experience in this area helps client administrators navigate within the rules - and sleep better at night. 

  VantagePoint is a team of industry experts who are dedicated to improving the business of medicine. With vast experience in executive management, operations, finance, clinical services and compliance, we deliver unparalleled, measurable and quantifiable results for our clients.


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