M.K. Wickens, PLLC, is a Health Care Fraud and Compliance company. Principal, Mary Wickens, JD, CFE has over 35 years experience in the Healthcare Insurance, Managed Care, and Compliance Industry. Her experience includes advising and counseling health care providers, insurers, government contractors, and others in compliance, ethics, fraud and abuse, Medicare, Medicaid and Federal Employees Plan, managed care, and other matters.
Internal Investigations - As a highly experienced investigator, Mary Wickens is available to provide swift and thorough review of potential compliance and ethics issues. She is seasoned at handling potential whistleblower concerns, C-suite investigations, and reporting for self-disclosures. She provides comprehensive, understandable reports and recommendations to executives, audit committees, and auditors.
Compliance Consulting - Ms. Wickens is experienced in providing site reviews, red team reviews, and independent compliance reviews. She has in-depth knowledge developing and implementing effective corrective action plans and extensive experience in responding to government and commercial audits and investigations.
Background Experience - Ms. Wickens is a former compliance officer for a major health insurer and former legal and compliance specialist for a CMS Medicare Program Safeguard Contractor. Also a former operations director for government programs (Medicare Part C, Medi-gap, and FEHBP) for a major HMO, she is experienced with government audits and investigations, commercial audits, as well as self-reporting and internal investigations.
Ms. Wickens has decades of experience as in house counsel to HMOs and health insurers. She has drafted, developed, negotiated, and implemented numerous healthcare provider-payor contracts, and developed and implemented codes of conduct, ethics programs, compliance programs and numerous corrective action plans. Ms. Wickens has authored numerous professional publications and presentations on health care fraud and compliance, government and commercial audits, compliance programs, and healthcare contracting.
This brief describes: Which government agencies and health care providers have power to act and what are those powers? Who controls testing and reporting results and who has the power to isolate individuals, impose quarantines and take other steps to mitigate the outbreak.
The US Department of Justice (DOJ) recently joined a federal qui tam lawsuit1 brought against a private equity firm that specializes in health care pharmacies. Notably, the case also charges individual partners of the private equity firm, Riordan, Lewis & Haden, Inc. (RLH) based in Los Angeles2. They are charged with violations of the federal Anti-Kickback Statute (AKS) and the federal False Claims Act (FCA) in connection with their management of Diabetic Care Rx/Patient Care America (PCA), a compounding pharmacy. The case involves reimbursements from TRICARE, the health care program for the military and their families.
Health care fraud and abuse cases are often won or lost on the effective use of expert witnesses. As health care fraud cases have become more complex and technical, the scope and use of expert testimony has proliferated, and the successful use of experts is one of the lawyer's most important jobs. False Claims Act, Anti-Kickback Statute, and Stark Law cases all demand various types of experts to assist the trier of fact in understanding the nature of the case, the morass of rules at play, the evidence, and a variety of billing, valuation, contractual, technical, and compliance concepts. Increasingly, expert reports and testimony play a pivotal role in motions for summary judgment, as well as at trial. Experts also are used in "conference room litigation," such as mediations or negotiations between defense counsel and enforcement agencies. This article is the result of interviews with health care fraud litigators and expert witnesses in the field who identified their best practices to produce optimum outcomes for their clients.
Research & Planning Consultants, LP (RPC) has been assisting clients with expert services for over 45 years, including consulting and expert witness testimony for personal injury, healthcare litigation, commercial litigation and Certificate of Need matters. RPC also offers a wide selection of health data. They have served clients across the U.S, from Alaska to Florida and from New England to California.
A Complete Team of Damages Experts for Personal Injury Litigation
Research & Planning Consultants, LP provides the following services:
PERSONAL INJURY - RPC provides comprehensive damages analysis in personal injury litigation. Their expert team has life care planners, vocational evaluators, board-certified physicians, economists and neuropsychologists.
Areas of Expertise include: Life Care Plans, Loss of Earning Capacity or Support, Present Value of Damages, Medical Bill Analysis, Chargemaster Analysis, Neuropsychological Testing & Traumatic Brain Injury, Vocational Evaluations, IMEs, Section 18.001, Prestanding ED Chargemaster Analysis
COMMERCIAL LITIGATION- RPC has provided expert analysis on commercial litigation concerning many industries: chemicals, refining, forestry, waste management, pipelines, water resources, oil and gas EDP, fisheries, agriculture, electrical generating plants, transmission lines, telecommunications, and real estate development. Our special expertise in the healthcare industry has proven valuable to business litigators unfamiliar with this complex industry.
Areas of Expertise: Breach of Contract / Commercial Economic Damages, Construction Disputes, Litigation over Non-Competitive Agreements, Environmental Torts and Toxic Torts, Commercial Disparagement, Wrongful Termination
HEALTHCARE LITIGATION - RPC offers economic, statistical, data and clinical analysis in a wide range of healthcare litigation. They have experience with payment disputes, qui tam litigation, physician-hospital disputes, practice valuations and construction litigation.
Areas of Expertise: Qui Tam Healthcare Litigation, Medical Staff Disputes, Professional Liability, Payment Disputes, Health Facility Construction Disputes, Freestanding ED Chargemester Analysis
CERTIFICATE OF NEED - RPC provides Certificate of Need (CON) planning services nationwide. We have over 35 years of experience developing regulatory strategy, preparing applications and testifying in public and administrative hearings.
Areas of Expertise: Satellite Hospitals, New Hospitals, Relocation and Transfer of Beds, Observation Beds, Geriatric Psychiatric Units, Children’s Hospitals, Comprehensive Inpatient Rehabilitation Units, Neonatal Intensive Care Units, Open Heart Surgery Services, Long Term Acute Care Units, Projects that exceed CON Capital Threshold Limits, Projects for Specifically Listed Services, Programs Requiring CON, Hospices, Senior Living Facilities
Ronald T. Luke, JD, PhD, is a principal consultant and President of RPC, LP. Ron joined RPC in 1976 and became its president and principal owner in 1979. He has consulted on projects for health care providers, managed care plans and public agencies in more than 25 states. He also serves as an expert witness in trials, administrative proceedings and legislative hearings.
Active in the Health Policy Arena, Dr. Luke has been accepted as an expert in Economics, Socioeconomic Impact Analysis, and Policy Analysis by state and federal courts, and state administrative agencies. The types of cases in which he has provided expert testimony include personal injury, contractual disputes, health care payment disputes, construction defects, utility construction permitting, and certificate of need. He has testified on health care matters including market structure, billing fraud and abuse, reasonableness of charges, medical staff credentialing, workers’ compensation fee guidelines, utilization review, physician contracts, and managed care contracts.
Kacy L. Turner, MS, CRC, CVE, CLCP, is a Certified Life Care Planner and Vocational Consultant with RPC. She has over 20 years of experience in Rehabilitation. Ms. Turner has experience writing life care plans for both plaintiff and defense clients. She has experience as a rehabilitation consultant in three states and has been qualified as a testifying expert in state and federal court.
Ms. Turner has worked on cases in several states as well as the country of Trinidad. To determine the pre-injury and post-injury employability in personal injury cases, she provides vocational testing, transferable skills analysis, job requirements analysis, rehabilitation plans, and definition of reasonable accommodations under the American with Disabilities Act. She is a member of the International Association of Rehabilitation Professionals, the Texas Association of Rehabilitation Professionals and Providers of Services, and Vocational Evaluation and Career Assessment Professionals.
Brian Piper, PhD, is an Economist with RPC specializing in Quantitative Analysis and Modelling. He works on a variety of cases including personal injury and certificate of need. He is experienced in data extraction, management, simulation, and analysis using STATA, SQL, ARC GIS and a variety of other programs. Dr. Piper has taught graduate classes in statistics and econometrics in both MBA and Ph.D. programs.
Dr. Piper is an experienced expert, providing testimony, reports, and affidavits on the issues of economic damages in personal injury litigation, healthcare litigation, False Claims Act litigation, and other commercial litigation. He has testified on behalf of plaintiffs and defendants.
Dr. Piper specializes in the economics of healthcare. He has been retained by healthcare providers and insurers in payment disputes. He has analyzed the reasonableness of charges and expected payment for past and future medical services for providers, insurers, plaintiffs, and defendants. Besides work in litigation, Dr. Piper has provided analysis of Certificate of Need applications and the economic impacts of proposed legislation.
This paper identifies and discusses industry standards for what charge percentile threshold state laws and private health plans consider reasonable to determine allowable amounts for payment. The term &"allowable amount"; refers to the total amount a regulation or private health plan determines a provider should be paid. It is the sum of the payment responsibilities of the plan and the patient.