Julie Nielsen

Ms. Nielsen focuses much of her work on assessing internal controls and regulatory compliance risks under Medicare, Medicaid, and commercial contracts; and assisting clients facing allegations of violations of the False Claims Act, Anti-Kickback Statute, or other legal, regulatory, or contractual requirements. She has detailed knowledge of the billing, payment, financial, and other transactional data systems maintained by various parties in the healthcare system. She specializes in marrying key transactional data, such as healthcare claims and member eligibility data, with her expertise in billing, coding, claims processing, and reimbursement. This enables her to provide clients with a more global view of the issues or allegations and enhances her ability to develop timely, independent, and supportable conclusions and opinions.

Over the past fifteen years, Ms. Nielsen has focused much of her work on assisting Medicare Advantage organizations (MAOs) with addressing government enforcement and regulatory compliance issues in the risk adjustment area. In particular, she has assisted MAOs, large physician groups and management services organizations, and private equity firms with:

• Performing operational and compliance risk assessments of Medicare Risk Adjustment (MRA) policies, programs, and practices, including coding policies and practices, retrospective chart reviews, health risk assessments, and prospective programs
• Working with counsel and MAOs to develop and implement compliance activities aimed at minimizing compliance and enforcement risks, particularly around MRA programs and diagnosis code capture
• Performing complex risk adjustment-focused data analytics using historical claims, encounter, and prescription drug data to identify other provider submissions or clinical indicators supporting the diagnosis codes submitted to the Centers for Medicare and Medicaid Services (CMS)
• Performing analyses of diagnosis code submissions by network providers to identify potential outliers for certain providers or conditions that may require further investigation
• Leading investigations into billing and coding practices by providers and third-party vendors, including extensive medical chart reviews to evaluate the documented support for diagnoses submitted to CMS and assisting MAOs with self-disclosures and submission of deletions of unsupported diagnosis codes
• Providing privileged consulting expertise and assistance to counsel for MAOs being investigated by the Department of Justice (DOJ) for potential false claims
• Assisting MAOs with responding to CMS and Office of Inspector General (OIG) risk adjustment data validation audits