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.
Milliman’s Tampa Office provides Health Insurance, Health Care and Employee Benefit Consulting to law firms, insurance companies, hospitals, HMO’s, Blue Cross/Blue Shield plans, employers and government agencies. Our staff is experienced with medical, dental, long-term care, Medicare supplement & critical illness.
We assist clients nationwide with forensic actuarial work, rate filings, regulatory compliance, reserve projections, valuations, employee benefit analysis and design, mergers and acquisitions, demutualizations, claim cost analysis, and utilization management programs.
These health care services are used in litigation relating to: