If you have been contacted by auditors or investigators from Qlarant Integrity Solutions (“Qlarant”), your practice could be at risk for recoupments, pre-payment review of future claims, loss of Medicare or Medicaid eligibility, and other penalties. Our federal defense lawyers represent Medicare and Medicaid-participating health care providers in Qlarant investigations and audits nationwide.
Qlarant Integrity Solutions (“Qlarant”) is a private contractor that performs Medicare and Medicaid audits and investigations on behalf of the Centers for Medicare and Medicaid Services (CMS). Although Qlarant is not a federal entity, it has been granted broad authority to impose penalties on the federal government’s behalf. Additionally, if Qlarant auditors or investigators uncover evidence of Medicare or Medicaid fraud, Qlarant is required to refer the provider to the U.S. Department of Justice (DOJ). These referrals can trigger invasive federal investigations that have the potential to lead to civil or criminal charges.
For health care providers that are facing Qlarant investigations and audits, engaging experienced defense counsel is critical to avoiding severe consequences. At Oberheiden, P.C., our federal defense lawyers represent providers in all Medicare and Medicaid matters nationwide. Our lawyers have broad experience dealing with Qlarant and CMS’s other “fee-for-service” audit contractors, and we have an extensive track record of protecting our clients against recoupments and other penalties. With a defense team that also includes internal auditors, former federal agents, and other non-lawyer experts, we are able to offer swift, comprehensive, and strategic advice, and we take an aggressive approach that is designed to resolve our clients’ investigations and audits as quickly and favorably as possible.
What is Qlarant Integrity Solutions?
Based in Easton, Maryland, Qlarant Integrity Solutions is a private business organization that has recently been awarded two separate contracts to conduct Medicare and Medicaid fraud investigations. It was formerly known as Delmarva Foundation for Medical Care, Inc. and Health Integrity, LLC. In 2018, CMS named Qlarant as its Investigations Medicare Drug Integrity Contractor (I-MEDIC) for conducting fraud investigations and audits related to Medicare Parts C and D, and that same year Qlarant was also selected as the Unified Program Integrity Contractors (UPICs) to conduct fraud investigations and audits related to all other Medicare and Medicaid programs in the following jurisdictions:
- American Samoa
- Mariana Islands
- New Mexico
- North Dakota
- South Dakota
Qlarant employs former federal law enforcement officers and other experts who have spent their entire careers focused on identifying fraud, waste, and abuse in the Medicare and Medicaid systems. According to Qlarant’s website,
“Qlarant . . . perform[s] various functions related to potential fraud, waste and abuse from prescribers, pharmacies, and beneficiaries . . . [with a] primary focus . . . on complaint intake and response, data analysis, assessing leads, investigative action, administrative actions and program integrity. . . .
“Qlarant . . . is a national leader in battling [fraud, waste, and abuse] and has offices and home-based associates across the country. . . . [It] uses a combination of advanced technology, data analytics, and expert evaluation to provide a powerful process consistent with CMS’s goals and expectations, which will ultimately benefit Medicare beneficiaries and recipients.”
What Do You Need to Know if Your Health Care Practice is Facing a Qlarant Investigation or Audit?
Although Qlarant is a private company and not a government entity, health care providers must not be lulled into a false sense of security. The fact that your practice is being targeted by Qlarant does not mean that your practice is off of the government’s radar; and, as mentioned above, Qlarant audits have the very real potential to lead to federal investigations. As a result, health care providers must approach Qlarant audits with the same caution and the same aggressive defense strategy that they would utilize during a federal health care fraud investigation.
1. What are Qlarant’s Investigators and Auditors Looking For?
Qlarant’s role as an I-MEDIC and a UPIC is to identify and deter fraud, waste, and abuse affecting the Medicare and Medicaid programs. In performing this role, it collects providers’ program billing data and examines their reimbursement requests through several different lenses. During a standard investigation or audit, Qlarant will be looking for evidence of:
- Billing for Medically-Unnecessary Services, Supplies, or Equipment – Medical necessity is a threshold requirement for all Medicare and Medicaid reimbursements. If a provider does not have adequate documentation to substantiate the medical necessity of the services, supplies, or equipment they have billed to Medicare or Medicaid (or if an investigator or auditor believes that a provider’s documentation is lacking), then there is a very high likelihood that Qlarant will impose substantial recoupment liability.
- Unintentional Billing and Coding Errors – Regardless of intent, if a health care provider has received payment from Medicare or Medicaid for improper billings, then the provider must reimburse the federal government. Billing and coding errors are often at the center of Qlarant investigations and audits, with each of the following types of mistakes having the potential to trigger recoupments and other penalties: double-billing, upcoding, unbundling, submitting the wrong billing code, and billing for services not actually provided.
- Intentional Billing and Coding Fraud – Qlarant investigators and auditors will be looking for evidence of intentional billing and coding fraud as well. If investigators or auditors find evidence of intent, not only can this lead to immediate liability, but it can also potentially set the stage for a criminal prosecution.
- Unlawful Financial Arrangements Between Providers – In addition to examining providers’ Medicare and Medicaid billings, Qlarant investigators and auditors will typically seek to examine providers’ financial arrangements with other professionals and entities. Accusations of Anti-Kickback Statute and Stark Law violations are common; and, while often misguided, these accusations can still create major issues for all types of health care providers.
2. How Does Qlarant Collect Providers’ Medicare and Medicaid Billing Data?
In addition to having direct access to health care providers’ billing data as a CMS contractor, Qlarant also has the authority to demand access to providers’ billing and patient records during investigations and audits. While many audits are fully remote, Qlarant investigators and auditors routinely visit health care providers’ places of business as well.
However, while Qlarant has the authority to demand that providers produce certain records for inspection, this authority is not absolute. For example, Qlarant cannot legally demand that providers disclose records that extend beyond the period of its review. Unfortunately, this does not prevent its investigators and auditors from asking, and providers must be extremely careful to avoid unnecessarily disclosing information that could expose them to liability.
3. What are the Potential Outcomes of a Qlarant Investigation or Audit?
The potential outcomes of Qlarant investigations and audits range from no liability to allegations of intentional Medicare or Medicaid fraud that trigger a criminal DOJ investigation. For most unrepresented health care providers, the outcome is typically somewhere in between these two extremes. However, with our attorneys’ and experts’ experience in federal health care fraud matters, we are frequently able to resolve our clients’ investigations and audits without the imposition of any recoupments or other penalties.
4. What are Some Potential Defense Strategies During Qlarant Investigations and Audits?
At Oberheiden, P.C., we utilize multiple defense strategies to protect health care providers during Qlarant investigations and audits. While we tailor our representation to the unique facts of each individual matter, our ultimate goal is always the same: to resolve the inquiry without any civil or criminal liability for our client.
Examples of defense strategies we use to protect health care providers during Qlarant investigations and audits include:
- Prompt and Aggressive Intervention – By promptly and aggressively intervening in Qlarant’s inquiry, we can prevent any overreaching and ensure that the scope of the investigation or audit is appropriately limited.
- Challenging Qlarant’s Methodologies – From relying on outdated Medicare or Medicaid billing rules to utilizing inapposite formulas, we can uncover many types of flaws in order to call the legitimacy of Qlarant’s determinations into question.
- Using the Available Documentation to Your Advantage – While unnecessarily disclosing records to Qlarant can be a mistake, our attorneys and experts know how to use the available documentation to demonstrate that there is not adequate evidence to support allegations of Medicare or Medicaid fraud.
- Demonstrating Good–Faith Compliance Efforts – Our attorneys and experts can also utilize your practice’s Medicare and Medicaid compliance policies to demonstrate that you have made good-faith efforts to comply with the law.
- Disputing Allegations of Fraud and/or Intent – If you are being accused of overbilling Medicare or Medicaid, we will vigorously dispute these allegations in order to prevent the imposition of unjust penalties and protect you against the risks of a federal civil or criminal investigation.
Request a Free and Confidential Consultation at Oberheiden, P.C.
Are Qlarant investigators or auditors examining your practice’s Medicare or Medicaid billings? If so, our defense team can protect you. To speak with one of our highly-experienced federal health care fraud defense lawyers in confidence, call 214-469-9009 or request a free initial consultation online now.