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P-R-E-P-A-R-E: Prevention and Response Cheat Sheet (DRAFT) by [deleted]

Prevention and Response

This is a draft cheat sheet. It is a work in progress and is not finished yet.


One of the 20/80 percent principles for implem­ent­ation of an effective compliance program is the prevention and detection of criminal conduct.


The Goals of Prevention include:
Program Oversight via the Inclusion of high level executives to oversee the program.
The completion of Risk Assess­ments which identify the organi­zations risks that are priori­tized based on severity, likelihood and impact.
Reduction of govern­mental settle­ments if invest­igated.

CMS publicly releases areas of high risk fraud (i.e., sudden changes in billing, spikes in billing, billing by inappr­opriate specia­lties, billing by inappr­opriate diagnoses, increases benefi­ciary compla­ints, along with geogra­phical changes in billing identify theft). It behooves organi­zations to assess these areas and implement internal controls.
For example, Harmony Healthcare Intern­ational (HHI) uses the PEPPER Report in conjun­ction with the RUGs Analysis to depict areas of further review and analysis. Our clients receive monthly audits and monitoring of high risk areas which is a compliance method for preventing systemic issues which may result in False Claims and exorbitant fines. This system in itself depicts knowledge and response to metrics the govern­ments deems risky.


How an organi­zation responds to a violation is equally, if not more important, than the original error. On a regular basis Harmony Healthcare Intern­ational (HHI) fields calls from organi­zations across the country. More often than not, the caller is unaware of the negative implic­ations resulting from an improper response to an issue. It is imperative that the response:
Includes an invest­igation which is prompt, through and conducted in a profes­sional manner.
Identifies the cause of the problem.
Implements a correction and a system to prevent from recurring.
Determines the need for transp­arency
In addition, the method­ology of the response and the process of invest­igation may require client attorney privilege. This decision requires insight and discussion via the legal and compliance consulting team.