Sugam Langer

Sugam has extensive experience providing regulatory compliance, advisory, and investigative services to private and public sector clients. She has successfully participated in several compliance audit reviews, including a variety of government investigations, gap analysis, and independent testing engagements for various organizations. She works with healthcare plans and compliance oversight teams to develop key measures using policies and procedures, and ongoing auditing programs that will ensure continuous effectiveness of claims review. She has developed oversight and dashboard monitoring reports used by healthcare organizations to monitor the progress of corrective action plans and operational and compliance programs. She has effectively evaluated claims billing, including its appeal and grievance processing, to ensure compliance with payor policies and contracts to determine eligibility of payment.

Sugam’s professional experience includes:

• Retained by a national provider of diagnostic and imaging services to perform a compliance effectiveness assessment of its programs. The review consisted of identifying areas of risk, assisting in the development of risk mitigation plans to help build upon the company’s culture of compliance. Provided compliance guidance and advised business leaders, while working with legal, corporate compliance, and regulatory divisions as necessary. Drafted a report concerning the program’s current state of compliance and effective solutions to better meet compliance requirements.
• Retained by a large multi-hospital corporation to perform a provider-based review of its various network clinics. The goal of this ongoing review is to determine whether each evaluated hospital and its applicable subsidiary clinics are meeting the Medicare provider-based regulations. Performed interviews with compliance personnel, collection of proof of such compliance, and drafting summary schedules for counsel with findings. Required to QC the work of a team of five individuals and prior to its submission to managing director and counsel.
• Drafted expert report in an arbitration on behalf of the client. Issues in the report concerned review of opposition experts’ theories, specifically application of contract language, and negate those assertions with industry and regulatory guidance. Focused on multiple claims including medical necessity, shared administration and coordination of benefits, complex claim reviews, payment processing, and procedural requirements of appeals.
• Engaged by the general counsel’s office of a healthcare provider to investigate whistleblower allegations involving the organization’s revenue recognition process, internal controls, and Sarbanes Oxley controls. Involved the collection of electronic documents and hard copy documents, financial analysis related to the alleged issues, witness interviews, and preparation of report to senior management.
• Participated in an audit reviewing processing of claims, rejects, and accepts within each of its active PBM platforms. Submitted report with findings evaluating the reviews conducted in accordance with Medicaid and other federal healthcare guidelines and regulations. Specially focused review on rejected cases, analyzing accuracy of rationales provided, accompanied by proper reject codes, and determination of correct amount of monetary distribution.
• Engaged by healthcare provider to perform a complete update of its policies and procedures concerning the appeals and grievances processes governed under Part C and D within the Medicare Managed Care Manual. Involved the collection of electronic documents and hard copy documents, concerning respective segments within the company. This engagement also required interviews with process owners to understand the then available operational practices and identify gaps in the processes.
• Engaged by a healthcare provider to perform a complete update of utilization management policies and procedures in line with state and federal regulations. Involved the collection of electronic documents and hard copy documents, concerning the then operable business practices. These practices were next compared to the legislative requirements applicable. Interviews and walk throughs with organization personnel provided necessary insight into current business as usual approaches, thereby outlining needed updates in an effort to mitigate risk.