James Rough, CHC, CFE, CCEP

James Rough, CHC, CFE, CCEP

Zionsville, Indiana, United States
3K followers 500+ connections

Join to view profile

About

Headquartered in Indianapolis, IN, SunHawk Consulting (SunHawk) is a team of highly…

Articles by James

See all articles

Activity

Join now to see all activity

Experience

  • SunHawk Consulting, LLC. Graphic

    SunHawk Consulting, LLC.

    Phoenix

  • -

    Phoenix, Arizona Area

  • -

    Phoenix, Arizona Area

  • -

    Phoenix, Arizona Area

  • -

    Phoenix, Arizona Area

  • -

    Phoenix, Arizona Area

  • -

  • -

    Phoenix, Arizona Area

  • -

    Phoenix, Arizona Area

Education

Licenses & Certifications

Volunteer Experience

  • Health Care Compliance Association (HCCA) Graphic

    Chair of Annual Arizona Regional Conference

    Health Care Compliance Association (HCCA)

    - Present 8 years 6 months

    Health

    HCCA Regional Conferences provide a forum to interact with local compliance professionals, share information about your compliance successes and challenges, and create educational opportunities for compliance professionals to strengthen the industry. This event is held in Arizona each year in November. If you have any questions please feel free to reach out.
    http://www.hcca-info.org/Events/AllEvents/RegionalConferences.aspx

  • Health Care Compliance Association (HCCA) Graphic

    Planning Committee for Board Audit and Compliance Committee Conference

    Health Care Compliance Association (HCCA)

    - Present 8 years 1 month

    Health

    The Health Care Compliance Association’s Board Audit Committee Compliance Conference is designed for healthcare organization board members, compliance officers, and senior leaders.

  • Arizona Ethics & Compliance Council Graphic

    Founding Member and Chair

    Arizona Ethics & Compliance Council

    - Present 13 years 2 months

    Health

    The Arizona Ethics and Compliance Council (AECC) was created in September of 2011. The council was formed to bring together local ethics and compliance professionals (be they chief compliance officers, general counsel, or any others with a responsibility for corporate compliance) on a regular basis; providing a forum to discuss and share research, best practices and benchmark policies and program.

    The group will meet on a quarterly basis at different locations throughout the Phoenix…

    The Arizona Ethics and Compliance Council (AECC) was created in September of 2011. The council was formed to bring together local ethics and compliance professionals (be they chief compliance officers, general counsel, or any others with a responsibility for corporate compliance) on a regular basis; providing a forum to discuss and share research, best practices and benchmark policies and program.

    The group will meet on a quarterly basis at different locations throughout the Phoenix area. Any and all ethics and compliance issues will be up for discussion and debate. There will also be occasional guest speakers brought in to speak on timely topics of interest for the members.

    At this time, there are no plans to institute any membership fees or dues. All companies are welcome including public, private and not-for-profit organizations.

  • Association of Certified Fraud Examiners (ACFE) Graphic

    Advisory Council

    Association of Certified Fraud Examiners (ACFE)

    - Present 10 years 10 months

    Education

    The ACFE Advisory Council is a council of fraud-fighting experts dedicated to the improvement and growth of the ACFE.

  • Society of Corporate Compliance and Ethics (SCCE) Graphic

    Planning committee of Annual Board Audit and Compliance Committee Conference

    Society of Corporate Compliance and Ethics (SCCE)

    - Present 8 years 1 month

    Health

    SCCE brings compliance training and networking to your neighborhood, with regional compliance conferences. These one-day events, hosted across the United States, include general and specialty sessions. Regional conferences offer professionals convenient opportunities for compliance training, updates on the latest news in regulatory requirements and enforcement, strategies to develop effective compliance programs, and of course, networking. See the listing below for upcoming dates in locations…

    SCCE brings compliance training and networking to your neighborhood, with regional compliance conferences. These one-day events, hosted across the United States, include general and specialty sessions. Regional conferences offer professionals convenient opportunities for compliance training, updates on the latest news in regulatory requirements and enforcement, strategies to develop effective compliance programs, and of course, networking. See the listing below for upcoming dates in locations ranging from New York to San Francisco and Alaska to Miami.

Publications

  • SEC Reports 35% Increase in FCPA Tips and Complaints

    ABA Section of Litigation, Criminal Litigation Committee

    Update on SEC's whistleblower program.

    Other authors
    See publication

  • ACFE Board of Regents is finalizing guidance on the limitation of Certified Fraud

    Arizona Chapter of Certified Fraud Examiners Quarterly Newsletter

    Current status of the Association of Certified Fraud Examiners, Board of Regents, review of draft Guidance and Interpretation of CFE Code of Professional Standards.

    See publication

  • Red Flag Account Descriptions Used to Conceal Bribes

    Arizona Chapter of Certified Fraud Examiners Quarterly Newsletter

    Rough provides insight on the Internal Financial Accounts companies and individuals may use to conceal and mischaracterize bribes.

    See publication

  • Comparison of 2012 and 2013 Medical Loss Ratio Rebates Under the Affordable Care Act

    Navigant Consulting

    Navigant’s James Rough has prepared three analyses which compare 2012 and 2013 rebates, due under the Affordable Care Act. In June, health insurance companies reported to the Secretary of Health and Human Services (HHS) that over $500 million in rebates were due to customers on August 1, 2013 under a small, but key provision in the Affordable Care Act known as the Medical Loss Ratio. The stipulation, referred to as the 80/20 rule by the White House, was touted earlier this month by President…

    Navigant’s James Rough has prepared three analyses which compare 2012 and 2013 rebates, due under the Affordable Care Act. In June, health insurance companies reported to the Secretary of Health and Human Services (HHS) that over $500 million in rebates were due to customers on August 1, 2013 under a small, but key provision in the Affordable Care Act known as the Medical Loss Ratio. The stipulation, referred to as the 80/20 rule by the White House, was touted earlier this month by President Barack Obama as a critical tool in keeping consumers' insurance costs down under the new federal health care law.

    Effective January 1, 2011, the Medical Loss Ratio required insurance companies to spend 80 percent (individual and small group markets) or 85 percent (large group markets) of premium dollars on medical care and healthcare quality improvement, rather than on administrative costs. When health insurers don’t meet these standards, they are required to rebate the difference to their customers in the form of a check or discount on the customer’s current policy.



    New data indicates many insurance companies are reporting higher Medical Loss Ratios, which means less rebates to consumers and businesses. Last year, $1.1 billion in rebates were disbursed to U.S. consumers. The Center for Consumer Information & Insurance Oversight reports that rebates disbursed in 2013 have dropped by more than half to $504 million.

    See publication

  • SEC Seeks Enforcement, Whistleblower Program Expansion

    ABA Section of Litigation, Criminal Litigation Committee

    James Rough and Joseph Roth of Osborn Maledon co-authored this update for the ABA Section of Litigation, Criminal Litigation Committee on the expansion of the SEC Whistleblower program.

    Other authors
    See publication

  • Health Insurance Rebate Checks Issued to an Estimated 10,000 Arizona Companies

    JD Supra

    One of the many provisions recently upheld by the Supreme Court in the Patient Protection and Affordable Care Act (ACA) requires health insurance issuers to maintain a minimum medical loss ratio (MLR) or they are required to rebate the difference to the policyholder. There are restrictions on distribution of the rebate, in this article Navigant Director James Rough and Scott Richardson from Jaburg Wilk address issues associated with the health insurance rebates.

    See publication

Projects

  • Moderated Panel for HCCA AZ Regional: Communicating with Regulators and Enforcement

    Communicating with Regulators and Enforcement: Avoiding Pitfalls
    James J. Rough, (Moderator) Navigant Consulting, Inc.
    Robert McAuliffe, (Panelist) U.S. Department of Justice, Civil Division, Commercial Litigation Branch (Frauds), Assistant Director
    Vanessa Templeman, (Panelist) Arizona Health Care Cost Containment
    System (Arizona Medicaid Program) Deputy Inspector General
    James Schwegel, (Panelist) Arizona Attorney General’s office, Supervising Special Agent -…

    Communicating with Regulators and Enforcement: Avoiding Pitfalls
    James J. Rough, (Moderator) Navigant Consulting, Inc.
    Robert McAuliffe, (Panelist) U.S. Department of Justice, Civil Division, Commercial Litigation Branch (Frauds), Assistant Director
    Vanessa Templeman, (Panelist) Arizona Health Care Cost Containment
    System (Arizona Medicaid Program) Deputy Inspector General
    James Schwegel, (Panelist) Arizona Attorney General’s office, Supervising Special Agent - Healthcare

    • Healthcare companies do their best to avoid receiving a regulatory inquiry
    a request for more information, or worse a subpoena. Management know
    all too well the consequences these types of requests can have on their
    reputation, bottom line, and their time
    • The panelists will provide a view into their Day-to-day work as regulators
    and enforcement officials through entertaining personal stories of real
    case studies
    • The panel will explore questions that every payer and provider will be
    interested in

    Other creators
    See project

  • Conducting Effective and Ethical Compliance Investigations

    Conducting Effective and Ethical Compliance Investigations - Presentation to Society of Corporate Compliance and Ethics
    Topics Discussed below:
    • Investigative protocols
    • Tips on effective witness interviews
    • Attorney-client privilege issues
    • Remedial action & self-reporting
    • Special challenges

    Other creators
    See project

  • Moderated Panel for HCCA Compliance Institute - Communicating with Regulators and Enforcement

    Communicating with Regulators and Enforcement: Avoiding Pitfalls at HCCA Compliance Institute,
    James J. Rough, (Moderator) Navigant Consulting, Inc.
    Crane Pomerantz, (Panelist) US Attorney’s Office, District of Nevada, Deputy Chief – White Collar Unit, Criminal Health Care Fraud Coordinator
    Shaun Bowen, (Panelist) State of Nevada, Office of the Attorney Genera, Deputy Chief Investigator
    Cynthia Santana, (Panelist) Federal Bureau of Investigation, Las Vegas Office, Supervising…

    Communicating with Regulators and Enforcement: Avoiding Pitfalls at HCCA Compliance Institute,
    James J. Rough, (Moderator) Navigant Consulting, Inc.
    Crane Pomerantz, (Panelist) US Attorney’s Office, District of Nevada, Deputy Chief – White Collar Unit, Criminal Health Care Fraud Coordinator
    Shaun Bowen, (Panelist) State of Nevada, Office of the Attorney Genera, Deputy Chief Investigator
    Cynthia Santana, (Panelist) Federal Bureau of Investigation, Las Vegas Office, Supervising Special Agent - Healthcare

    • Healthcare companies do their best to avoid receiving a regulatory inquiry
    a request for more information, or worse a subpoena. Management know
    all too well the consequences these types of requests can have on their
    reputation, bottom line, and their time
    • The panelists will provide a view into their Day-to-day work as regulators
    and enforcement officials through entertaining personal stories of real
    case studies
    • The panel will explore questions that every payer and provider will be
    interested in

    See project

  • Moderated Panel for HCCA AZ Regional: Communicating with Regulators and Enforcement

    Communicating with Regulators and Enforcement: Avoiding Pitfalls
    James J. Rough, (Moderator) Navigant Consulting, Inc.
    Lon Leavitt, (Panelist) US Attorney’s Office, District of Arizona, Civil Health Care Fraud Coordinator
    Derrick Francis, (Panelist) Arizona Health Care Cost Containment System (Arizona Medicaid Program) Deputy Inspector General
    James Schwegel, (Panelist) Arizona Attorney General’s office, Supervising Special Agent - Healthcare

    • Healthcare companies do…

    Communicating with Regulators and Enforcement: Avoiding Pitfalls
    James J. Rough, (Moderator) Navigant Consulting, Inc.
    Lon Leavitt, (Panelist) US Attorney’s Office, District of Arizona, Civil Health Care Fraud Coordinator
    Derrick Francis, (Panelist) Arizona Health Care Cost Containment System (Arizona Medicaid Program) Deputy Inspector General
    James Schwegel, (Panelist) Arizona Attorney General’s office, Supervising Special Agent - Healthcare

    • Healthcare companies do their best to avoid receiving a regulatory inquiry
    a request for more information, or worse a subpoena. Management know
    all too well the consequences these types of requests can have on their
    reputation, bottom line, and their time
    • The panelists will provide a view into their Day-to-day work as regulators
    and enforcement officials through entertaining personal stories of real
    case studies
    • The panel will explore questions that every payer and provider will be
    interested in

    See project

  • Moderated Panel for HCCA AZ Regional: Communicating with Regulators and Enforcement

    Communicating with Regulators and Enforcement: Avoiding Pitfalls
    James J. Rough, (Moderator) Navigant Consulting, Inc.
    Lon Leavitt, (Panelist) US Attorney’s Office, District of Arizona, Civil Health Care Fraud Coordinator
    Vanessa Templeman, (Panelist) Arizona Health Care Cost Containment System (Arizona Medicaid Program) Deputy Inspector General
    James Schwegel, (Panelist) Arizona Attorney General’s office, Supervising Special Agent
    Amanda Dean, (Panelist) Arizona Department of…

    Communicating with Regulators and Enforcement: Avoiding Pitfalls
    James J. Rough, (Moderator) Navigant Consulting, Inc.
    Lon Leavitt, (Panelist) US Attorney’s Office, District of Arizona, Civil Health Care Fraud Coordinator
    Vanessa Templeman, (Panelist) Arizona Health Care Cost Containment System (Arizona Medicaid Program) Deputy Inspector General
    James Schwegel, (Panelist) Arizona Attorney General’s office, Supervising Special Agent
    Amanda Dean, (Panelist) Arizona Department of Health Services, Department of Behavioral Health Services, Chief of Corporate Compliance

    Other creators
    See project

  • Moderated Panel for Arizona Chapter ACFE: Communicating with Regulators and Enforcement

    Communicating with Regulators and Enforcement: Avoiding Pitfalls
    James J. Rough, (Moderator) Navigant Consulting, Inc.
    Lon Leavitt, (Panelist) US Attorney’s Office, District of Arizona, Civil Health Care Fraud Coordinator
    Vanessa Templeman, (Panelist) Arizona Health Care Cost Containment
    System (Arizona Medicaid Program) Deputy Inspector General
    James Schwegel, (Panelist) Arizona Attorney General’s office, Supervising Special Agent - Healthcare

    • Healthcare companies…

    Communicating with Regulators and Enforcement: Avoiding Pitfalls
    James J. Rough, (Moderator) Navigant Consulting, Inc.
    Lon Leavitt, (Panelist) US Attorney’s Office, District of Arizona, Civil Health Care Fraud Coordinator
    Vanessa Templeman, (Panelist) Arizona Health Care Cost Containment
    System (Arizona Medicaid Program) Deputy Inspector General
    James Schwegel, (Panelist) Arizona Attorney General’s office, Supervising Special Agent - Healthcare

    • Healthcare companies do their best to avoid receiving a regulatory inquiry
    a request for more information, or worse a subpoena. Management know
    all too well the consequences these types of requests can have on their
    reputation, bottom line, and their time
    • The panelists will provide a view into their Day-to-day work as regulators
    and enforcement officials through entertaining personal stories of real
    case studies
    • The panel will explore questions that every payer and provider will be
    interested in

    Other creators
    See project

Honors & Awards

  • Navigant Client Service Hall of Fame, 2010

    Navigant Consulting

  • Navigant Client Service Hall of Fame, 2009

    Navigant Consulting

Recommendations received

3 people have recommended James

Join now to view

More activity by James

View James’ full profile

  • See who you know in common
  • Get introduced
  • Contact James directly
Join to view full profile

Other similar profiles

Explore collaborative articles

We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.

Explore More

Add new skills with these courses

See all courses