James Rough is President of SunHawk Consulting, LLC. a U.S. based Disputes, Compliance and Investigations Consulting Firm with experts in the Healthcare, Life Sciences, and Insurance Industries. Mr. Rough is a Certified Healthcare Compliance Professional, Certified Fraud Examiner, Certified Compliance and Ethics Professional and graduate of FBI Citizen’s Academy. Mr. Rough has also served on the Audit Committee of the Board of Directors for two entities and is adjunct professor focused on Healthcare Compliance, for the Masters of Legal Studies Compliance Program, at Arizona State University, Sandra Day O’Connor, College of Law.
For 20 years, U.S. and international clients have trusted Mr. Rough to perform independent fraud investigations, compliance effectiveness assessments; consult on complex contract disputes including quantification of damages; perform complex data analytics on large datasets and perform sample selections using various methods. He has also served as an independent technical advisor to State Auditors and the Centers for Medicaid & Medicare Services (CMS). Mr. Rough’s unique combination of formal financial, fraud and forensic training is coupled with significant experience in various healthcare industry segments and familiarity with associated large transactional, financial, and regulatory data sets. This knowledge base provides clients with a multi-faceted expert when they are facing compliance, internal and external investigation, litigation, financial accounting, and other compliance challenges.
Mr. Rough regularly advises clients on multiple topics, including the False Claims Act, Affordable Care Act, Stark Law & Anti-Kickback Statute, Medical Loss Ratios (MLR), Usual and Customary Rates in Healthcare Industry, Claims Data Analytics, Fraud Prevention and Investigation, Statistics including proper use of RAT-STATS software and technical accounting for revenue recognition. Mr. Rough’s healthcare clients include some of the nation’s largest insurers, hospital systems, global medical device/implant manufacturers and utilization managers.
Mr. Rough has led or had significant roles in high-profile forensic investigations and compliance reviews domestically as well as in Europe and the Middle East. Mr. Rough has provided significant support to clients communicating complex issues to regulatory and enforcement personnel, including the Department of Justice (DOJ) and Health and Human Services (HHS) - Office of Inspector General. He has communicated investigation and/or audit findings directly to CMS, State Medicaid Auditors, and to the Securities and Exchange Commission’s (SEC) enforcement personnel. Mr. Rough has also served as a non-testifying subject matter expert to white-collar defense counsel in high-profile criminal DOJ, civil SEC, and class action proceedings.
Mr. Rough is a regular lecturer for the Health Care Compliance Association (HCCA) on best practices for Communicating with Government Regulators and Enforcement personnel and Investigations. Mr. Rough serves as Chair of the annual Arizona Regional Conferences for HCCA and Society of Corporate Compliance and Ethics (SCCE), serves on planning committee for the HCCA and SCCE’s Annual Board Audit and Compliance Committee Conferences and on the planning committee for the HCCA annual Indiana Regional Conference. Mr. Rough is also Chair of the Arizona Ethics and Compliance Council and is and adjunct professor for Arizona State University, Sandra Day O’Connor, College of Law.