Navigating Healthcare Compliance and Fraud: Insights from a Legal Expert

In the latest episode of Compliance Conversations, host Dr. CJ Wolf sits down with Rebecca Busch, a healthcare compliance expert with over four decades of experience. From her early days as a trauma nurse to her current role as a sought-after expert witness, Rebecca has seen it all in the ever-evolving world of healthcare compliance and fraud. 

What Makes an Expert?

One of the most fascinating parts of Rebecca’s story is how she became a trusted expert witness. When she first started, she asked a simple question: “What makes someone an expert?” The answer wasn’t immediate, but over the years, through continuing education, certifications, and a lot of hands-on experience, she built an impressive CV. 

For Rebecca, it’s all about staying current. “I anticipate something new every year,” she explained. With healthcare compliance constantly changing, especially with new coding rules and regulations, staying educated is the key to success in this field. Whether you’re in internal audit, compliance, or legal consulting, staying ahead of trends will help you avoid pitfalls. 

Legal Challenges in Compliance: Where Fraud Meets Reality

One of the key highlights of the episode was Rebecca’s insight into the legal side of compliance. She shared stories of real cases, ranging from radiology billing errors to massive fraud schemes. 

Her mantra? Understand what’s normal, and assume everything else is abnormal. 

Rebecca explained how she uses her experience in coding and auditing to help attorneys build cases, often relying on her deep knowledge of healthcare regulations to identify discrepancies. As she puts it, “The variations in compliance are endless.” That’s where her expertise comes in—identifying what’s wrong and presenting it clearly to the legal teams. 

Expert Testimony: How to Survive a Deposition

For those who might find themselves called upon as expert witnesses, Rebecca offered some invaluable advice. "Know your material inside and out," she emphasized. Preparation is key, not just for writing expert reports, but for handling depositions as well. She also highlighted the importance of active listening, stating that most communication in depositions is non-verbal. 

Key Takeaways for Healthcare Compliance Pros

Rebecca’s experiences offer a wealth of knowledge, especially for those in compliance, coding, or legal roles within healthcare. Here are a few key takeaways: 

1. Stay Current: Always be aware of new rules and regulations.  
2. Be Prepared: Whether it’s a deposition, audit, or internal review, knowing your material and being ready to explain it clearly is crucial to success. 
3. Understand the Bigger Picture: Compliance is about more than just following rules. It’s about keeping the integrity of the healthcare system intact, and sometimes that means going beyond the expected to do the right thing. 

Tune In Now

If you’re interested in learning more about the legal intricacies of healthcare compliance, don’t miss this episode of Compliance Conversations. Rebecca Busch’s insights are a masterclass in navigating the complexities of fraud, compliance, and expert testimony.  

Transcript

CJ: Welcome everyone to another episode of Compliance Conversations. I am CJ Wolf, with Healthicity, and today's guest is Rebecca Busch. Welcome to the podcast, Rebecca!  

Rebecca: Well, thank you so much. I'm happy to be here.  

CJ: We are so grateful that you're willing to share your experience, your expertise, and your insights. Before we get into our topic, we'd love to hear from you a little bit. Just tell us a little bit about yourself. You know, maybe your professional background, what you're doing, those sorts of things.  

Rebecca: Sure! I'd be happy to. I'm going to give you my 360 Rebecca Busch tour.  

CJ: Love it! 

Rebecca: I actually started off in healthcare, believe it or not, at a very young age, it goes back all the way to 8th grade when my grandmother got sick and my dad would pick me up at 6:00 in the morning, and she was in the hospital with the stroke. And literally, I was at her bedside for that entire summer, 12-hour days, you know, 6:00 AM till like 9:00 PM when you went home at night. And so how about that for an introduction to healthcare?  

And I haven't stopped ever since. It was actually my driver to go to nursing school. And then I had another milestone event in my career. I had someone in my family that got sick. So, I started off as a trauma intensive care type nurse and I had someone that got sick and it put me down this path of, like, compliance and medical auditing because I needed structure so I can take care of family outside. How about that for a typical nursing route? The how we adjust.  

And that honestly, it just opened up to a world that I never thought I would be in. And my career just was driven by my experience and some of it I went into internal audit because things kind of, you know, break down in a hospital and you have to figure out how to fix them. And then sometimes my career took another turn. Where things kind of passed that grey line and it got me into that whole world of healthcare fraud examination.  

And it's just been one experience after another and at one point I got calls from attorneys that would say; "Hey, can you help me understand this particular matter?" and boom, that opened the door to providing expert testimony.  

And so it's been a runway since. And I'm telling you with having, I have to admit, you know, four decades of healthcare experience, I anticipate something new every year and I anticipate some kind of continuing education to help put the latest puzzle together. How's that for an intro?  

CJ: That's awesome! I love it! Yeah, it's always fun to talk to guests, to see how they ended up where we are because none of us probably envisioned it, but we kind of found our way into this world of compliance and fraud, waste, abuse, those sorts of things. And so, appreciate that background. And that's actually what we're, you know, the legal aspect of that is what I was hoping we could pick your brain about today because you have so much experience in that area, maybe we just kind of start off with you generally explaining the kind of legal matters that you're typically dealing with.  

Rebecca: Sure! The very first case that I got involved with was actually a compliance billing issue, where an attorney called up and asked me to look at a group of radiology bills and I was like; "Oh no, they can't do that." And I'm mixing in my internal audit, my compliance, my coding background, like all into one piece thing and it used to be my teaching example forever and I would get up in front of a class and I would say; "Hey, what do you think of a radiologist performing a history and physical office exam?" and so forth and they kind of look at me like; "No, that's not normal."  

And so and so the whole thing of my legal career started off. And this is like actually one of my mantras is; "Alright, I need to understand what's normal and then you can assume everything else is abnormal because the variations that occur are just endless."  

And then actually when I when I did that first case, I remember talking to a couple of attorneys and I would ask them, I said; "Okay, well, what makes somebody an expert?" like how do you start? you know, what's involved with that? And then he's like: "Well, you know, what did you go to school? Yes. Did you do graduate studies? Yes."` And then he went down the road map of; "Well, what other credentials do you have? continuing education? Yes. Do you publish? Yes." So, if you look at my CV on or about the age of 30, I was like; okay, I just started like co-authoring or writing articles. And then I went to different credentials. Like, I'm a certified fraud examiner fellow I have risk management, whatever associations I belong to, I start off doing journal articles and so forth. And before you know it, you just pick one activity each year, just pick one, and then all of a sudden 10 years go by and you look at your CV and it's like, but you know; "How did I do all this?" you just do one thing at a time and all of a sudden it just adds up. And believe it or not, amongst all that teaching is like my favorite thing to do, whether it's peers, patients, what have you just getting out there and talking to people.  

CJ: Yeah! Well, that's fascinating! Can you share a little bit about what some of your most interesting cases might have been? Do you have some of those top of mind?  

Rebecca: They're all over the map, okay! So, if you think about compliance and what's normal in healthcare, you've got a patient, you got a provider, you got a payer. And if you have, if you do any compliance work in that segment, something always goes wrong. And then there's intentional stuff that goes wrong. So, you know, there's always the funny ones. And that's funny and not funny at the same time. But, you know, I had a set of healthcare bills, and the doctor was in a difficult situation because the patient, he wasn't aware of the fact was deceased. So, you have to be alive to get stuff. And then, you know, sometimes you have mishaps like that and then sometimes you have more serious ones. It was called the Rent-a-Patient scheme, if you like Google that, where you have a group of providers that would literally target employees, recruit them for healthcare services, provide them services that they don't need, and then feel like crazy. So, that's kind of like on the fraud side.  

On the compliance side, you know sometimes you know I get cases where the person is being penalized for doing the right thing. So, I had one where it was a compliance officer, she reported the fraud, she stacked the fraud. She was trying to stop what was going on within the organization. And she was fired as a result of that. And so sometimes people will look at my CV and my healthcare background, they'll say; "Well, wait a second, why are you involved in a retaliatory discharge case?" right? 

CJ: Right! 

Rebecca: Because it was retaliatory, right? Well, it's because, you know, she chose to do the right thing. She chose to file the compliance stuff, so I actually was coming into it from a compliance perspective. The reason why we have compliance officers is because you know, we kind of want to keep the integrity of the organization. So, literally, they're just, they're really, they've been all over all over the map.  

CJ: Yeah! You know, from a coding and billing perspective, are there any kind of trends that you see, or it's just, it's like hit or miss, or do you see, I mean you've been doing it for so many years, is there anything that's like; "Hmm! This has happened a bunch of times?"  

Rebecca: Well, what happened? You know what? Sometimes I like to use this analogy. You know how the IRS we all, you know, we should be, earning money we should be filing tax returns, right? You know how the IRS is constantly changing rules? You go to your CPA and they're like; "Okay, what are the tax breaks can I take advantage of? What are the latest rules?" right? And so that analogy is great to think about coding. What are the latest rules? Because what people do is they push the envelope. And there's a difference between pushing that envelope and then just creating a new one and applying the rules in a manner that is just incorrect. So, I'd say the best way to stay on top of the trends would be to follow what the latest rules are, because those are the ones that they're going to break.  

And then if you do consulting work in it, it makes sense that if you follow, if you look at what are the latest rules? "Hey, this is where clients and organizations are also going to need help in, I need to make sure that I educate myself on that." And if I could tell you one quick story because I just remembered. Remember 2010? What happened in 2010?  

CJ: Was that for the Affordable Care Act?  

Rebecca: Yes. So, at the company I work at, I always grant internships for all high school kids. That's like an employee benefit. I come up with something. And so one of my nurses is like; "Oh, can you give my son an internship?" And I said; "Well, what is he studying?" "He's studying political science." Sapd; "Great, I have a project for him!" So I had him come in. I had him get us an Excel spreadsheet out and here was the, here's his summer internship sheet 1, he had to read every word of the legislation of the Affordable Care Act, and sheet 1 I want you to write down all the rules that have to do with healthcare. Sheet 2, document any other rules that have nothing to do with healthcare. And then he did it. And then I sat down with them and I said; "Which list was longer?" And he said; "Sheet 2. I don't understand it." I said; "Welcome to political science!" you know. So, you know, and it was an exercise; one, to give them an introduction, you got to read legislation, and two, if you remember what I just said a few minutes ago, I'm always mindful of the latest rules. Why? Because that's where my clients are going to need help. And then when it comes to expert testimony, that's where you're going to have conflict, where people are going to be looking for experts on; "Okay, how do I navigate through these rules and how does that impact these set of facts?" So, it's really, it's typical, so you know.  

CJ: Yep! That's a really good example. You know, one that comes to mind for me and I don't know if you've dealt in this space, but you know, chronic care management was kind of these new codes, Medicare was going to cover them.  

Rebecca: Right!  

CJ: And then you get all these parties entering the healthcare system thinking; "Okay, we're going to set up a great way to do chronic care management," and it's almost like, of course, there are people that are, you know, most people in healthcare are doing things for the right reason, but then there's people that kind of want to take advantage of the fact that; "Oh, Medicare is now going to pay for this. So, they try to set up some sort of slick process or model that's going to, you know, make them rich and this and that. And so then, you know then the years play out, and then you see all these settlements related to chronic care management.   

Rebecca: Right!  

CJ: To your point about kind of just staying on top of the rules, because whatever's new, whatever's different, just wait a year or two and that's where the enforcement's going to be. 

Rebecca: That's right! And so, one of the things I always tell, whether you're just doing traditional compliance, internal audit or if you are actually involved in the investigative side, you should just go to cms.gov and print the OIG's audit work plan and read it, because they published, these are things that we're going to audit. Well, guess what? The things that they have on there are the things where they have seen problems in the past and it's a great guide post. 

CJ: Exactly!  

Rebecca: I've never met a compliance or internal audit department that had enough staff to do all the things that, Okay, they just, that's just the unfortunately the nature of the culture of it. So, if you need ideas on how to triage or prioritize, I would look at that work plan because that is telling you they've identified areas and that's a good resource, a good self-guidance, learning and what have you as I tell my three adult children, by the way, and two of them are going into healthcare; "You know what you're stuck with continuing education. Education is just part of life, Okay?"  

CJ: That's right. That's right! 

Rebecca: Treat, treat it as a vitamin.  

CJ: That's right! Take it every day. I love it. I love it.  

Rebecca: Take it every day!  

CJ: Yeah, well, these are great conversations so far. Let's we're going to take a quick break and kind of come back and ask you some more questions. So, bear with us, everyone for a moment.  

Welcome back everyone from the break. We're talking to Rebecca Busch, who has years and years of experience and expertise in legal matters relating to compliance and coding reimbursement, those sorts of things. Rebecca, maybe we can get a little bit deeper into kind of your legal experiences as an expert witness, you're probably going to be deposed, right?  

Rebecca: Yes!  

CJ: Yeah! So, any tips or maybe first just tell us what a deposition is, cause most of our listeners will know, but just kind of explain what that is and then any tips for, if you are an expert witness, how to survive a deposition so to speak. 

Rebecca: Sure! You know what? I'm going to give you like an overview. So, first of all, once you're done with your expert report and you turn it in. So that really is like the first stage because now the other side is going to want to look at your report and you may go to something called a discovery deposition, and the purpose of that is for them, they have an opportunity, usually 3 hours, sometimes they get more, to ask you questions about your report and understand the basis they say it for your opinion. Why are you staying? Why are you providing the opinions that you are? And evidence depth is, this is the actual testimony that will be used at trial. So, it's actually like going to trial. So, I've done all of those. I have about 500 believe it or not, under my belt of that experience! 

CJ: Wow!  

Rebecca: And the most important and I'm and you know and I'm always trying to mentor people to get involved with it. The most important thing, whether it's your first time, or the fourth hundred time, is you just got to know your material. You have to be prepared. So, if you think about it like anything else, you know your stuff, you're the expert. You're the one that generated the report. So, just doing your homework, the second thing, and this I've actually that people who really want to get involved take a class on how to conduct an interview from an investigative standpoint and I'm going to tell you why, because you all have experience that you're not aware of and believe it or not, like 70-80% of communication is nonverbal, so active listening and learning to answer the question would probably be phase 2 of managing a deposition and or trial.  

So, the first is knowing your stuff, OK, know it inside and out. And then two, is learning how to be an active listener and answering the questions that are asked. Those are probably the two key you know attributes that I would think that is important and prepare yourself and if you ever have a client, especially if it's your first one or two, actually even now. You know, if I've never worked with an attorney before, you know, I tell him you got to talk to me before trial. I can't just walk in cold because I need to understand your style and words, right? We all use terms of art. You know, you want to make sure that you have a handle on their communication style. So, when they ask you a question, you're kind of like; "Wait, you haven't heard, you haven't used that term in our prior conversation." So, I think those would be that high-level considerations that I would keep in mind.  

CJ: Good, good tips! So how about any hurdles, roadblocks, or headaches that you encounter in this expert testimony experience? And if there are any of those, do you have any recommendations on how to approach those types of things?  

Rebecca: You know what, that's a great question. And so, a lot of my work is like narrative and spreadsheets. And so, I had a situation once for whatever reason, you know, the first hard lesson I hate to tell you this is; that there are things you can't control. So, if you have an attorney who didn't produce your entire report, especially in two parts, you just have to deal with it and the judge wouldn't allow a portion of my report, so the statements that are important. I make sure they're in all documents. So, if one gets cut loose, you're there. So, there's certain you know, in my opinion, to a medical degree of audit certainty, blah blah blah, I make sure it is in any individual attachments. That's one thing. 

CJ: Right!  

Rebecca: The other lesson is unlike a visual person, I love pictures. And so, a lot of times you prepare your report, your part gets accepted into Evans, and then the attorney may want; "Well, I want to use a demonstrative evidence." Meaning, like, you know, I want to, you know, I want to here's a picture, right? I want to show a picture. And the judge says; "No!" So, any charts or pictures that I think are good visuals to communicate to a jury, I put them in my report because then it's already accepted. So, these are just like minor little, you know, tidbits but goes back to making sure that your report, you know, you should have that internal staff or someone peer review it, can stand on its own without you, that you are obsolete with your report, with you know, with just your report. That's probably one of the biggest skills to develop.  

CJ: So are most of these, I'm assuming most of these are like federal False Claims Act cases. Is that accurate, is it other laws?  

Rebecca: Types of work, yeah! So, I do do a lot of fraud-related cases, but I have a bunch that are not. There's just typical, you know, like one type of case that I have a lot of, especially for like the coding folks that are on the call, you know, whenever you have car accidents or any kind of what they call third party liability, they need to introduce bills into evidence.  

So, a great faraway for people who have a compliance and coding background is they just want to know; "Hey, are these healthcare bills usual, customary, and reasonable?" And so you're basically using your training to introduce bills into evidence.  

There's other work that I do like life care planning, where the parties injured, and they want to know; "All right, well, how does this impact their life, and what healthcare services are they going to need in the future to address the injury?" There are all kinds of caveats. Specifically, the compliance, another one is I had a software failure case where a provider purchased an electronic health record system, it just didn't have what it promised it was going to have. It was, it was like a nightmare!  

CJ: Got you!  

Rebecca: So really, if you think about, you know what, this is one way to do a self-assessment, right? Do workflow of your job, for all of you guys listening to this, I get up at 8, here's the functions that I work in. These are the services that I provide. These are the skill sets that I use. So, that then becomes your recipe; "Hey, you know what? I can be an expert on any of these day-to-day work activities," and then you build from there because that's in essence what people are looking for. They're looking for a better understanding of a particular event in a certain setting. It's a great self-assessment.  

CJ: Yeah, that makes a lot of sense. So, you mentioned this life care plan, maybe we go a little bit deeper into that. What's your process for constructing a life care plan like that?  

Rebecca: Well, there is an organization that's involved with life care planning. And so it's a discipline, I use my case management and nursing background and my coding background and my finance background, where I interview the medical records and the respective providers and let's say a person got in a car accident and you know they're going to need a knee replacement, right? It's very clear with smashed, and so forth what have you and then I start listening to the doctors and they say; "I'm going to need this type of surgery, that type of surgery." Then I go and I find the right coding language from a compliance perspective, I get the coding down for that service and then I retrieve a price.  

So, in healthcare, what do we do? We we're always communicating. In the past, we go what did we do and why? What is the procedure code? The why is the diagnostic code? So, if you have a past experience with that when you're projecting stuff into the future, you're like; "Okay, well, what does he need and why?" So, then you retrieve the proper procedure codes and the diagnoses codes, then you research; "Well, how much does it cost for that CPT code?" Then you get your projection.  

Well, do you see that? So, it's kind of like in most people who have a healthcare background, I mean you've got some exposure to that, right? I don't know anyone that well I should say 99% of the people out there you touch the healthcare system, right? You go and you see your doctor.  

CJ: Yeah, that makes a lot of sense. Right, right!  

Rebecca: Am I fine? "Yeah!" Do I need anything in the future? "Yay. Nay." right? And so, it's professionally applying that process into the future. It's an interesting niche.  

CJ: Yeah, it is! So, you mentioned pricing. How do you research those prices? Are you looking, cause a lot of like payers don't publish, you know what their allowable amount is, or something non-Medicare does, right? Like they've got their medical fee schedule.  

Rebecca: Right! Sure!  

CJ: But when it comes to the actual pricing, are there any tricks or researching? 

Rebecca: Yes. Well, first of all, there is an organization called Fair Health. If you Google it, they allow consumers to actually plug in CPT codes and you can get some prices. Also, the Veterans Administration has a tool where they collect that pricing data that you can also submit this. So, if you learn to navigate it, and then most states have a workers comp site that's usually like what they call it, the 85th percentile, meaning that 85%, you know or more providers charge this price that you as a consumer can access it. So, there are data repositories that are capturing data by CPT code, by DRG group, by ambulatory patient group. So, if you know the genre of the healthcare service that's to be received, you can get the group, then you get the price.  

CJ: So, I'm going to ask a very specific question here and maybe you'll have to explain this to our audience and to me. But the Daubert standard, so what is that and how do you kind of get ahead of any motions that involve that?  

Rebecca: Another great question! So there's case law at federal and, you know, state level that basically says; "Okey, this is what qualifies you to be an expert." And anyone who wants to get involved in that, they should just Google the federal attributes, you know for experts and just kind of read them. And when I talked to you earlier remember I told you the story when an attorney said to me what makes someone an expert? that's your list. It begins with that.  

And so, the biggest way that they challenge you on a Daubert meaning; "Hey, you're really not an expert in the product that you produce," really isn't you know objective doesn't file scientific methodology, what have you. You mitigate that, one; by following the rules, two; by identifying your scope of work. Three; being really the visual that I like to keep to have people get in mind is if you ever took like physics or chemistry in high school, you ever do a lab report? You know the lab report how you have to put down here's the hypothesis, here's my ingredients. Here's my methodology. This is how I did it. And here are my conclusions.  

CJ: Exactly!  

Rebecca: If you follow that component and the field that you're in, you're going to meet the standard, okay? Because in essence is, you know, it's not like, it's not like our parents growing up, why do you have to do it? Well, because I said so, right? So, as an expert, you can't walk in there and say, well, it's because I said so and this is what I think, right? You have to actually create a recipe so someone can understand how you analyze the information and how did you get from point A to point B. That's what they're doing when you hear people challenging the expert, they're saying their report is flawed or it's either the report is flawed or you don't have the training and education to be giving it, you know to provide an opinion on that particular subject, does that help a little bit?  

CJ: That that does. That's fascinating. And I know our listeners are loving this, because we haven't really done this topic before and I am so grateful for your experience and expertise, we're kind of coming to the end of our time, though we could talk all day. I would love to hear more. Any last-minute nuggets or thoughts or encouragement or anything you want to say before we close here today?  

Rebecca: Sure! You know, there's one area of experience that I advocate. So, at NBA, we give back and we give back by taking, you know so many people a year that get stuck in healthcare and we solve their problem, we actively advocate for them and I'm going to tell you it's been a PhD every time and I'm most proud of an individual. Like, if you ask me all the things I've done, I had this 28-year-old out of the blue call me and as she found my name by bantering with someone on Facebook, ask her. I had her send me everything, a 100% of her bill was denied. And she was on this $30,000 monthly payment plan with the provider. I looked at everything and I just like; ah! did one of my rolling my eyes, you went through the emergency room? It's you know, there are rules about out-of-network they have to pay it.  

CJ: Right!  

Rebecca: I wrote up a letter, you know, I used my compliance background, my training to help an individual on the frontline. So, if you're in your organization, listen to those like patient complaints or listen to how people fall through the cracks. And that gives you an outside perspective of how the organization runs. I'm telling you, they're nuggets of gold of knowledge. So, you know, it feels good too when you help someone out and you and you accomplish something and you help someone navigate somewhere they're stuck.  

CJ: Yeah, I love that. I had that experience recently with a loved one who came to me. They knew I the field I'm in and they came to me and they're like; "I got this bill and it's like, you know, $15,000." And I was only there for like 2 hours. Like, and they didn't do anything. They just put me in a room and like; "Well, let me, you know, get the documentation, send me the bill." I was looking at, and I'm like; "Yeah, it looks like on their hospital chargemaster, they may have just had fat fingers when they were typing in and they typed in, you know, 220 units of this time period instead of two."  

Rebecca: Exactly!  

CJ: And then I help them navigate and who to call and how to kind of complain in a way that's going to get heard. And they're like; "Yeah, we made a mistake. This should have been 2, not 220." So, it took the bill down from, you know, the $15,000 down to like the $800 range. And that made more sense for this person and so it, like you said, it feels good to kind of use all this knowledge to help somebody out.  

Rebecca: And you know what you just did? You just gave a great sidebar example that if you're ever testifying as an expert, you've demonstrated your knowledge. How about that?  

CJ: There you go! Rebecca, this has been such a joy. Thank you so much for taking the time to share your experience. 

Rebecca: Thank you! 

CJ: And to all of our listeners; thank you for listening to another episode. If you know of other topics that you'd like us to cover, please reach out to us. And if you know of other speakers or guests that we could invite, please, please share that information with us. We want this podcast to be useful to you.  

Rebecca: All right!  

CJ: Awesome! Thank you everybody! Until next time, take care! 

Rebecca: Thank you!