Payer Disputes

From our work in market access and commercial strategy, we have gained an understanding of the organizational structure and processes of many payer and provider organizations. We have assessed damages in cases involving claims payment disputes and provided analyses in litigations involving fraudulent conveyance allegations, contract disputes, and antitrust/pharmaceutical pricing issues. We have amassed considerable experience reviewing, cleaning, and analyzing large databases of payer entities across many years.

We have also conducted statistical analyses of medical claims audits, as well as complex statistical sampling projects to resolve billing disputes between providers and insurers. Our specific experience includes:

  • Statistical analysis of government program billings, such as Medicare and Medicaid
  • Evaluation of economic issues in fraudulent billing cases
  • Estimation of damages from claims, including fraud and illegal pricing
  • Review of accounting records and documentation in cases of alleged irregularities
  • Review of financials restated to remove the effects of fraud

Our analytical models include statistical sampling and benchmarking techniques of health care claims to identify patterns of unusual billing practices and to value the liability or damage associated with overpayment of claims. We have frequently applied statistical sampling techniques to make inferences about a population when analyzing claims processing and payment for managed care as well as fee-for-service plans.

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