Healthcare Fraud & Abuse Compliance Analyzer
Assess healthcare contracts & billing for OIG/DOJ fraud risk instantly
What You Can Do
Analyze healthcare contracts, billing patterns, and business relationships against OIG/DOJ regulatory frameworks to identify fraud and abuse exposure. Receive a structured risk score, compliance gaps, and actionable remediation steps. Detect arrangements that may trigger False Claims Act liability or Anti-Kickback Statute violations before they become compliance crises.
Features
Evaluates contracts against OIG guidelines, Anti-Kickback Statute (AKS), Stark Law, False Claims Act (FCA), and state fraud and abuse laws.
Generates a 0-100 compliance risk score correlated to OIG/DOJ enforcement priorities, identifying high-exposure arrangements.
Analyzes billing codes, frequency patterns, and referral relationships to spot upcoding, unbundling, or suspicious utilization trends.
Pinpoints missing written agreements, inadequate documentation, and unmet safe harbor requirements with specific remediation steps.
Structures financial relationships between parties, remuneration arrangements, and indirect ownership to surface hidden kickback risks.
Ranks issues by severity and OIG enforcement likelihood, so you address the highest-impact gaps first.
Evaluates compensation packages against fair market value standards and identifies volume-based or referral-tied components that may violate AKS.
Example Output
Example 1: Referral Agreement Risk Assessment
Risk Score: 72/100 (HIGH RISK)
Primary Concerns:
• Remuneration tied to volume of referrals (potential AKS violation)
• No written agreement documenting fair market value determination
• Billing pattern shows 40% referral increase post-agreement
Compliance Gaps:
✗ Missing written safe harbor documentation
✗ No FMV justification for compensation level
✗ Lack of audit trail for referral tracking
Recommended Actions:
1. Engage legal to document FMV analysis
2. Remove volume-based remuneration component
3. Implement referral tracking audit procedures
Example 2: Billing Anomaly Detection
Risk Score: 45/100 (MODERATE RISK)
Anomalies Detected:
• 25% billing increase in Q3, no volume increase (upcoding suspect)
• Bundled service frequency 3x above peer benchmarks
• 12 claims denied in 90 days for missing documentation
Recommendation: Full billing audit of Q3 claims
What's Included
- OIG Regulatory Checklist: Comprehensive checklist mapping AKS, Stark Law, and FCA requirements to contract terms and billing practices.
- Risk Scoring Framework: Proprietary algorithm weighting OIG enforcement history, arrangement type, and compensation structure for accurate compliance scoring.
- Compliance Gap Templates: Actionable remediation templates for fixing missing agreements, documentation, and safe harbor compliance issues.
- Billing Pattern Analysis Guide: Methodology for detecting upcoding, unbundling, and utilization anomalies correlated to referral relationships.
- FMV Documentation Framework: Structured approach to documenting fair market value determinations and defending remuneration decisions to regulators.
Who It's For
- Compliance Officers
- Healthcare Attorneys & In-House Counsel
- Billing Managers & Revenue Cycle Directors
- Internal Audit & Risk Management Teams
- Practice Administrators & Clinic Managers
Best For
- Physician referral agreement compliance reviews
- Vendor and contractor arrangement audits
- Billing code and utilization pattern analysis
- Pre-contract fair market value assessments
- Regulatory risk triage for suspected violations
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