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Determine the scope of your internal investigation

Healthcare Auditing Weekly, December 9, 2003

The scope of your internal investigation depends on what prompts it. Use the following guidelines to determine the scope of an internal investigation:

1. What kind of issues the investigation raised. Develop a list of issues that you think in-house counsel should know about, so they can help you determine whether to conduct the internal investigation. Include a range of issues, especially those that involve violation of health care statutes and regulations, such as submissions of fraudulent billing, false claims, upcoding, kickbacks, and overpayments.

2. How the problem arose. If the government has started investigating your organization, your internal investigation should shadow the government's every move. Find out the subject of the government's investigation by interviewing employees the government has contacted, contacting the lead investigator, interviewing key employees, and reviewing important documents before the government reviews them. The following factors also affect the scope of your internal investigations:

· The number of persons or business units involved in the misconduct

· The extent to which mid-level and senior management was involved in the misconduct

· The length of time over which the misconduct occurred

· Whether the misconduct affected any government-related services or enforcement efforts

· Whether the misconduct was prohibited under the company's compliance program

· Whether a civil lawsuit will likely follow

· Whether the issue is limited to a human resource problem

· Whether there is likely to be adverse publicity

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