Module 1 deep dive · Leadership LMS · Advanced
Map enforcement escalation paths
Who oversees what, how they find your skilled nursing facility, how escalation moves from a complaint to federal enforcement — and exactly how first contact usually happens. Assumes compliance-leader fluency; new staff start with Compliance Foundations — escalation paths explained.
Who is over what — agency by agency
Federal oversight flows through the Department of Health and Human Services and the Centers for Medicare & Medicaid Services. States conduct surveys on the Centers for Medicare & Medicaid Services’s behalf. Medicare claims run through Medicare Administrative Contractors; overpayments through Recovery Audit Contractors; fraud investigations through Unified Program Integrity Contractors; criminal and exclusion authority through the Office of Inspector General and the Department of Justice.
Escalation ladder — how scrutiny intensifies
Most facilities do not jump from silence to indictment. Scrutiny typically climbs this ladder as documentation errors repeat or fraud indicators appear.
How an auditor finds you & makes first contact
Different actors use different channels. Train your administrator, DON, business office, and compliance lead to recognize each one — and route it correctly.
Cross-referrals — when one agency hands off to another
State survey findings and billing errors do not stay in silos. These handoffs are the escalation paths compliance leaders must anticipate.
Practice this live in the workshop
Module 1 walks your team through real scenarios — then Modules 2–4 show how Patient-Driven Payment Model case mix, diagnosis coding, and state survey findings connect to the same charts federal auditors pull.