When the facts matter most
When allegations, disputes, or regulatory scrutiny arise, healthcare organizations need to understand what happened, assess their exposure, and determine the right path forward.
Delays or incomplete information can heighten legal, financial, and reputational risk. Clear, fact-based insights help leaders respond with confidence, resolve issues, and remain focused on delivering quality patient care.
BDO helps healthcare organizations and their counsel respond with confidence. We provide independent investigations, forensic analysis, litigation and arbitration support, compliance monitoring, expert witness services, risk assessments, and dispute resolution support tailored to the unique realities of healthcare. Our teams combine deep industry experience with advanced analytics and AI-enabled insights to evaluate complex facts, identify patterns, uncover root causes, and translate data into actionable intelligence. BDO professionals provide the human oversight, interpretation, and judgment necessary to deliver meaningful outcomes.
Our professionals include former healthcare regulators, inspectors general, physicians, nurses, compliance leaders, reimbursement specialists, and forensic investigators with firsthand experience across provider, payer, and government settings. We understand how healthcare organizations operate, how reimbursement systems function, and how regulators, auditors, and enforcement agencies evaluate risk.
Whether addressing an emerging concern, responding to an investigation, supporting litigation, or strengthening compliance programs, BDO delivers independent insight, analytical rigor, and healthcare expertise organizations need to make informed decisions, resolve disputes, and protect their mission of delivering quality patient care.
How BDO Can Help
BDO offers healthcare forensics and investigations services to help your organization achieve its goals.
Uncover the Facts
We investigate hotline complaints, whistleblower allegations, media reports, and other concerns to establish facts, assess risk, and support informed decision-making.
Navigate Regulatory Scrutiny
We provide independent investigations, forensic analysis, reporting, and expert support in response to government inquiries, audits, enforcement actions, and compliance reviews.
Resolve Payment Disputes
We evaluate reimbursement disagreements, claims denials, billing disputes, and payer-provider conflicts to identify root causes, quantify impacts, and support resolution.
Strengthen Compliance and Oversight
We assess governance structures, compliance programs, internal controls, and regulatory requirements to identify vulnerabilities and help organizations mitigate risk.
Turn Data Into Insight
We leverage advanced analytics and AI-enabled tools to detect anomalies, identify patterns, uncover root causes, quantify exposure, and deliver fact-based insights.
Trusted Advisors in Complex Healthcare Matters
Supported 470+ healthcare investigations, litigation matters, regulatory reviews engagements as testifying experts over the past five years.
Deep healthcare and regulatory expertise built on decades of collective industry experience, including a former HHS Inspector General, and a former HHS OIG Chief Medical Officer.
15+ professional certifications & licenses including clinicians, certified coding professionals, actuaries, forensic accountants, and former government oversight.
74% of clients engaged the HC Forensics and Investigations team on additional matters during the past five years.
Healthcare Forensic Capabilities
When healthcare disputes involve complex clinical, operational, financial, and regulatory issues, you need credible analysis and clear communication to understand the facts, assess potential exposure, and determine the right path forward. We help organizations and counsel evaluate allegations, develop fact-based positions, and explain complicated healthcare matters in ways that judges, juries, and arbitrators can understand. Our multidisciplinary teams include former government oversight, healthcare operators, and forensic professionals who bring real-world healthcare experience to complex legal proceedings.
Our healthcare litigation support and expert witness services include:
- Healthcare litigation and dispute advisory
- Expert witness testimony
- Rebuttal expert services
- Class action support
- Arbitration and mediation support
- Damages analyses
- Lost profits analyses
- Healthcare operational dispute mediation
- Valuation and financial analyses
- Medical necessity dispute resolution
- Statistical sampling and extrapolation
- Deposition preparation
- Trial support
- Regulatory and compliance opinions
- Independent expert reports
Your clinical, financial, and operational data holds valuable insights, but finding the signal amid the volume can be difficult. Advanced analytics can help you uncover meaningful patterns, identify emerging risks, understand anomalies, and address concerns before they become larger problems. With clearer information, you can make informed decisions and respond with confidence.
We can help you uncover meaningful patterns, anticipate developing issues, identify emerging risks, and provide meaningful context behind anomalies and irregularities. With the right information, you can make informed decisions and prepare measured responses to questions before they become larger problems.
Our healthcare advanced analytics, forensic analytics, and AI-enabled insight services include:
- Claims analysis and analytics
- Predictive compliance
- Outlier detection
- Fraud detection
- Billing pattern analyses
- Utilization analyses
- Referral pattern analyses
- Network analyses
- Statistical sampling
- AI-enabled risk identification
- Data mining
- Data visualization
- Population-level investigations
- Financial impact modeling
- Clinical documentation analytics
- Monitoring dashboards
Government inquiries, whistleblower allegations, fraud concerns, and False Claims Act matters can expose your organization to significant legal, financial, and reputational risk. Timely, objective analysis can help you clarify the facts, assess potential exposure, and take informed action to protect your organization and move forward with confidence. We can help you evaluate a situation objectively and understand what happened, assess potential exposure, and determine an informed path forward through independent analysis and our deep familiarity with healthcare regulations and obligations.
Our False Claims Act, fraud, and government investigation services include:
- False Claims Act (FCA) investigations
- Fraud and kickback inquiries
- Qui tam investigations
- Department of Justice (DOJ) investigations
- Office of the Inspector General (OIG) investigations
- Unified Program Integrity Contractor (UPIC) audits
- Recovery Audit Contractor (RAC) appeals support
- Medicaid investigations
- Self-disclosure support
- Fraud assessments
- Allegation testing
- Financial quantification
- Statistical sampling
- Medical necessity reviews
- Claims reviews
- Root cause analyses
- Independent fact development
Payment delays, denials, underpayments, and contract disputes can disrupt cash flow and put significant revenue at risk. Our team of experienced healthcare payment integrity professionals can help you evaluate disputed claims, understand reimbursement issues, quantify financial impacts, and navigate conflicts with commercial and government payers using data-driven analysis and extensive industry knowledge.
Our provider-payer dispute and reimbursement controversy services include:
- Underpayment disputes
- Claims adjudication
- Contract compliance reviews
- Managed care disputes
- No Surprises Act disputes
- Out-of-network reimbursement
- Downcoding investigations
- Medical necessity denials
- Diagnosis-Related Group (DRG) disputes
- Coverage disputes
- Payment integrity disputes
- Healthcare revenue recovery
- Audit response
- Contract interpretation support
- Arbitration support
Allegations, compliance concerns, and regulatory obligations can expose healthcare organizations to significant legal, financial, and reputational risk. We conduct thorough independent investigations and oversight engagements grounded in facts, not predetermined outcomes. We follow the evidence and provide findings that help counsel, regulators, and leadership teams make sound, informed decisions. And we serve as appointed monitors in cases where discipline, experience, and objectivity are priorities.
Our independent investigation, IRO, and monitorship services include:
- Internal investigations
- Independent review organization (IRO) services
- Corporate integrity agreement support
- Monitorships
- Board-directed investigations
- Executive concerns investigations
- Compliance failure reviews
- Data breach investigations
- Billing investigations
- Fraud, waste, and abuse (FWA) investigations
- Governance assessments
- Root cause analyses
- Corrective action planning
- Ongoing monitoring
Incomplete or inaccurate clinical documentation can trigger payment disputes, compliance concerns, and regulatory scrutiny. We can help you proactively assess whether medical records, coding decisions, and supporting documentation accurately reflect the services provided, and address concerns related to billing practices, medical decisions, claim support, and documentation integrity.
Our medical record, coding, and clinical documentation review services include:
- Medical necessity reviews
- Coding accuracy assessments
- ICD-10 reviews
- Current Procedural Terminology (CPT) reviews
- Healthcare Common Procedure Coding System (HCPCS) reviews
- Medical records review services
- DRG validation
- Clinical validation
- Documentation assessments
- Physician documentation reviews
- Utilization reviews
- Quality of care evaluations
- Retrospective chart reviews
- False Claims Act (FCA) claim reviews
- Extrapolation support
- Peer reviews
Undetected compliance vulnerabilities can escalate into costly complaints, investigations, and enforcement actions. We can help you proactively evaluate your compliance programs, discover vulnerabilities, and strengthen oversight processes before concerns escalate. Our approach combines healthcare operational experience, regulatory insight, and data-driven assessments to support proactive risk management.
Our compliance, program integrity, and regulatory risk assessment services include:
- Healthcare compliance monitoring
- Compliance program assessments
- Program integrity reviews
- Risk assessments
- OIG guidance alignment
- Compliance effectiveness evaluations
- Regulatory readiness reviews
- Policy assessments
- Monitoring program design
- Auditing program evaluations
- Corrective action planning
- Third-party risk analysis
- Board reporting
- Compliance analytics
- Predictive compliance assessments
Revenue cycle breakdowns and payment integrity challenges can disrupt cash flow, delay reimbursement, and weaken financial performance. We can examine your revenue cycle performance, identify process breakdowns, assess payment integrity challenges, and address managed care concerns. Our forensic consultants are well versed in Medicare Advantage and other contracted, publicly funded, or private insurance supplement plans. We provide practical insights into issues affecting cash flow, reimbursement, timeliness, and overall financial health.
Our revenue cycle, payment integrity, and managed care advisory services include:
- Revenue cycle assessments
- Denial management
- Underpayment identification
- Contract optimization
- Managed care strategy
- Revenue integrity
- Charge capture
- Clinical Documentation Integrity (CDI) optimization
- Cash acceleration
- Payment integrity
- Revenue leakage assessments
- Payer performance analyses
- Revenue Cycle Management (RCM) transformation
- Managed care contracting support
- Revenue cycle analytics
Technology-enhanced. Human-led. Built for Defensibility.
BDO combines advanced analytics and AI-enabled tools with experienced healthcare, compliance, clinical, and forensic professionals. Technology helps us identify patterns and focus investigative efforts, while experienced practitioners provide the judgment, context, and validation needed to help organizations reach well-supported defensible conclusions.
Forensics & Investigations Insights
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Frequently Asked Questions
We assist healthcare organizations and counsel with internal investigations, whistleblower allegations, government inquiries, False Claims Act matters, billing and coding concerns, reimbursement disputes, compliance reviews, and other matters involving regulatory scrutiny or potential misconduct. Our teams perform independent fact-finding, forensic analysis, medical record reviews, financial quantification, and reporting to help organizations understand facts, assess risk, and determine appropriate next steps.
We use advanced analytics to identify unusual billing patterns, utilization trends, referral relationships, coding anomalies, and other indicators of potential compliance, operational, or financial risk. These insights can help organizations investigate concerns, strengthen oversight, and address issues before they develop into disputes, audits, investigations, or enforcement actions.
We help providers evaluate denials, underpayments, contract compliance concerns, payment integrity issues, and other reimbursement disputes. By combining healthcare operational experience with financial, regulatory, and forensic analysis, we help organizations quantify impacts, establish facts, and build defensible positions in negotiations, arbitrations, and litigation.
Yes. Our professionals provide expert consulting, expert witness testimony, rebuttal opinions, damages analyses, statistical sampling support, and independent expert reports in healthcare litigation, arbitration, investigations, reimbursement disputes, and regulatory matters.
Yes. We assist healthcare organizations and counsel with False Claims Act investigations, qui tam allegations, whistleblower complaints, government inquiries, Office of Inspector General matters, and related healthcare fraud investigations. Our work includes independent fact development, claims reviews, financial quantification, and root cause analysis.
An Independent Review Organization (IRO) provides objective assessments of healthcare operations, billing practices, claims, compliance programs, and regulatory obligations. Organizations frequently engage IROs in connection with Corporate Integrity Agreements, government settlements, compliance concerns, or proactive oversight initiatives.
Advanced healthcare analytics can identify unusual billing behavior, outlier providers, referral relationships, utilization anomalies, and claims patterns that may warrant further review. These techniques help organizations focus investigative resources and continuously monitor for emerging risks.
AI-enabled tools can help analyze large volumes of clinical, financial, and operational data to identify patterns, anomalies, and areas that may warrant further review. At BDO, AI serves as a decision-support tool within a human-led investigative process. Our healthcare, clinical, compliance, and forensic professionals evaluate, validate, and interpret analytical results to provide context, improve efficiency, and help organizations reach reliable, defensible conclusions.
We serve health systems, hospitals, physician groups, academic medical centers, laboratories, ambulatory providers, managed care organizations, health plans, private equity-backed healthcare organizations, long-term care providers, and healthcare counsel.
Organizations often engage forensic consultants when responding to allegations, government investigations, litigation, whistleblower complaints, reimbursement disputes, compliance concerns, data anomalies, or situations requiring independent analysis and reporting.
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