Overview

Melissa Scott is a Managing Director with The Claro Group. She heads the national Healthcare Consulting Practice, which focuses on disputes, investigations, and litigation support. Her clients include provider-based organizations, payers, and law firms. Her specialties include healthcare operations, forensic analytics, litigation support, provider/payer reimbursement disputes, internal audit, regulatory compliance, investigations, monitorships, and related government mandated claims and transactional reviews. Ms. Scott is Certified in Healthcare Compliance, a Certified Professional Coder, and Certified Healthcare Internal Audit Professional. She has served as faculty for Defense Criminal Investigative Service (DCIS), Federal Bureau of Investigation (FBI), and Special Investigation Unit (SIU) agents in conjunction with CEU-approved training for the Accredited Healthcare Fraud Investigator (AHFI) credential, working with the National Healthcare Antifraud Association as well as Americas Health Insurance Plans' Fraud, Waste & Abuse work groups. She has been published in several industry journals, including Compliance Today and the Association of Healthcare Internal Auditor's New Perspectives, in addition to authoring a chapter in the Health Law Practice Guide for the American Health Lawyers Association.

Experience +

Stabilized operations for a bankrupt hospital system and implemented measures for cash flow acceleration to maintain operations through the COVID pandemic, achieving a successful sale.

Provided co-sourcing to internal audit department, assisting with the development of internal audit plan and execution of quarterly audits, including development of board-level reports. Audits included claims reviews, pharmacy implementation, 340B, clinical trials, construction, and finance.

Conducted and end-to-end assessment of risk adjustment data capture and flow to ensure complete and accurate reporting of required information facilitating reimbursement. Assessment included practices originating with the health system and provider documentation and tracked data flow through payer adjudication and reporting to the Centers for Medicare & Medicaid Services.

Served as an extension of the SIU for the largest single health carrier in the U.S., among others. Provided independent and objective investigation of suspect providers, including review of medical records, claims data, licensure, accreditation, onsite inspection and live interviews. Assisted in-house/outside counsel with over payment recovery efforts.

Provided risk mitigation services for one of the largest multi-institutional Catholic health care delivery systems in the nation, including external investigations, internal audit/monitoring, and compliance infrastructure development. Managed response to government inquiries and recoupment requests.

Assisted with the investigation of a $200 million fraud perpetrated through a Critical Access Hospital, whose magnitude rose to the attention of national news media. Investigated the validity of claims, identified co-conspirators, participated in depositions, mediations and related legal proceedings.

Testifying expert in False Claims Act matter related to peripheral vascular testing. Provided independent and objective analyses of medical records and claim at issue, as identified by whistleblowers. Drafted expert report, delivered deposition and jury trial testimony.

Conducted independent and objective investigation into criminal allegations against a primary care physician. Identified negligence of third-party billing company, which caused the appearance of improper patient care and billing by provider.  Presented findings to FBI, DCIS, and U.S. Attorney’s office in defense of client, who was cleared of wrongdoing.

Provided expert services related to the validity of clinical laboratory receivables that were relied upon as collateral in order to secure a $40 million line of credit, which was subsequently exhausted while the laboratory was left in bankruptcy. Drafted report and supported settlement negotiations.

Serve as Independent Review Organization for providers under Corporate Integrity Agreement with the OIG, as well as Monitor for Certificate of Need compliance.

Education +

S. Business Management, Linfield College, 2004

Certifications +

Certified in Healthcare Compliance (CHC) - 2006

Certified Professional Coder (CPC) - 2007

Certified Healthcare Internal Audit Professional (CHIAP) - 2019

Memberships +

American Academy of Professional Coders

Association of Healthcare Internal Auditors

Health Care Compliance Association

Publications & Speaking Engagements+

“Clinical Laboratory Compliance: Something Old, Something New,” (with Dinh Nguyen), ASCP LabMedicine, July 2009.

“Understanding the Importance of Genetic Test Code Modifiers,” ADVANCE for Medical Laboratory Professionals, January 2010.

“Waived Laboratory Tests: Meeting Regulatory Requirements and Implementing Best Practices,” HCCA Compliance Today, July 2010.

“Sign on the Dotted Line,” ADVANCE for Medical Laboratory Professionals, January 2011.

“Next Level Laboratory Audits: Adopt a Bidirectional Approach,” AHIA New Perspectives, June 2011.

“Fundamentals of Medical Coding & Reimbursement,” Health Law Practice Guide, April 2012.

“Operating Ethically,” ADVANCE for Medical Laboratory Professionals, January 2013.

“BCR-ABL Capture,” ADVANCE for Medical Laboratory Professionals, February 2013.

“CBC Billing,” ADVANCE for Medical Laboratory Professionals, March 2013.

“Reimbursement Rates: Billing a Client Less than Medicare/Medicaid Reimbursement can be a Grey Area,” ADVANCE for Medical Laboratory Professionals, April 2013.

“Provision of Phlebotomy Services,” ADVANCE for Medical Laboratory Professionals, May 2013.

“Interim MoPath Reimbursement,” ADVANCE for Medical Laboratory Professionals, June 2013.

“Clinical Laboratory Investigation,” AHFI-Approved CEU Presentation, National Health Care Antifraud Association Annual Training Conference, Orlando, Florida, November 2013.

“Understanding the Codes: Molecular Pathology Investigation,” AHFI-Approved CEU Presentation, National Health Care Antifraud Association Annual Training Conference, Orlando, Florida, November 2013.

“Clinical Laboratory Red Flags,” AHFI-Approved CEU Presentation, National Health Care Antifraud Association Skills & Schemes Conference, Coronado, California, November 2013.

“Investigating Laboratory Services,” AHFI-Approved CEU Presentation, National Health Care Antifraud Association Annual Training Conference, San Diego, California, November 2015.

“Conducting a Laboratory Audit,” AHFI-Approved CEU Presentation, National Health Care Antifraud Association Annual Training Conference, San Diego, California, November 2015.

“Functional Medicine FWA Investigation,” AHFI-Approved CEU Presentation, National Health Care Antifraud Association Annual Training Conference, San Diego, California, November 2015.

“Drug Assays,” AHFI-Approved CEU Presentation, National Health Care Antifraud Association NETS Webinar, March 2016.

“Urine Drug Assays,” Medical Director’s Presentation, America’s Health Insurance Plans Fraud, Waste & Abuse Work Group, Webinar, May 2016.

“Laboratory Schemes & Red Flags,” (with Jeannie O’Donnell), AHFI-Approved CEU Presentation, National Health Care Antifraud Association Skills & Schemes Training Conference, Dallas, Texas, July 2016.

“Clinical Laboratory FWA Investigation,” Presentation, Farmers Insurance Special Investigation Unit, Webinar, February 2017.

“Drug Assays,” Presentation, America’s Health Insurance Plans Fraud, Waste & Abuse Work Group, Webinar, April 2017.

“Clinical Laboratory Auditing: Chart to Bill,” (with Jeannie O’Donnell), CPE-Approved CEU Presentation, Association of Healthcare Internal Auditors Annual Meeting, Atlanta, Georgia, August 2017.

“Interview: How Hospitals Can Know When to Outsource Revenue Cycle Management,” Healthcare Finance, March 2018.

“Aesthetics Market Outlook,” Presentation, Aesthetic Practice Symposium, Portland, Oregon, December 2018.

“Aesthetics Marketing Strategies,” Presentation, Aesthetic Practice Symposium, Portland, Oregon, December 2018.

“Juliet Nd:Yag Laser: Innovations in Gynecologic & Dermatologic Tissue Remodeling,” Presentation, Aesthetic Practice Symposium, Portland, Oregon, December 2018.

“Issues Facing Community & Critical Access Hospitals: What is the Answer and When is it too Good to be True,” (with Frank Terzo, Nelson Mullins, and Carol Fox, B. Riley), CLE Presentation, American Bankruptcy Institute Insolvency Symposium, Grand Cayman, Cayman Islands, January 2019.

“Aesthetics Market Outlook,” Presentation, Aesthetic Practice Symposium, Seattle, Washington, May 2019.

“Aesthetics Marketing Strategies,” Presentation, Aesthetic Practice Symposium, Seattle, Washington, May 2019.