James Rough, CFE, CHC, CCEP, is President of SunHawk Consulting, LLC. For 17 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 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 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 & Human Services (HHS) - Office of Inspector General (OIG). 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. Mr. Rough serves as Chair of the annual Arizona Regional Conferences for HCCA and Society of Corporate Compliance and Ethics (SCCE) and on planning committee for the HCCA and SCCE’s Annual Board Audit and Compliance Committee Conferences. Mr. Rough is also Chair of the Arizona Ethics and Compliance Council.