Disputes and Investigations.

Funding and service-delivery in the healthcare industry are governed by unique and complex contractual arrangements and regulatory structures between various entities. The byproduct of this structure becomes frequent contractual or regulatory investigations and disputes that involve industry-specific issues and large volume transaction data sets. This multifaceted environment, when combined with the significantly expanded False Claims Act ("FCA") and Qui Tam allegation risks under Fraud Enforcement and Recovery Act of 2009 ("FERA"), makes this industry the focal point for investigative and dispute activities. In addition, many health programs that are governed by traditional government contracting regulations have seen ever increasing scrutiny and risks associated with applying these regulations, that were originally created for a manufacturing or project based accounting structures, to the complex service and process based operating model required to process claims and perform other ancillary services. With our expertise in compliance, data analytics, state and federal regulations, and the healthcare industry, HealthScape Advisors is a valuable resource to companies and their counsel confronted with these challenges.

Services

We provide services in support of counsel in each of the key phases of an investigation or dispute including:

  • Providing expert testimony
  • Serving as consulting experts
  • Conducting data analysis on large transaction sets
  • Performing damages analysis
  • Supporting class certification defenses based on industry practices
  • Providing factual support for voluntary disclosures
  • Preparing responses to Federal and State regulatory actions
  • Implementing corrective action and remediation
  • Determining impact quantifications

Representative Experience

Investigations

  • Performed an investigation of alleged Medicaid program fraud related to a capitated behavioral health delegation agreement with a large health plan. Compiled historical encounter data submission in response to a federal subpoena.
  • Assisted a Medicare Contractor with a voluntary disclosure of mispayments as the result of incorrect implementation of claims edits and audits. As part of this engagement, we met with internal and external counsel and presented our results to CMS management. We worked directly with senior individuals at CMS to resolve the issues identified.
  • Assisted a Medicare Contractor with a Medicare False Claims matter, which involved, reviewing documents provided under subpoena or discovery in order to reconstruct the chronology of events, understand the accounting implications of those events and calculate the potential monetary exposure related to the events in question. Engagement included the analysis of large volumes of transactions or data to quantify the effect of issues identified by counsel and identify trends or biases that may indicate improper acts. Deliverable included performing statistical sampling of volumes of data to allow for sample testing and extrapolation of results to support settlement discussions.
  • Assisted a large health plan in responding to a demand inquiry from a State Medicaid Agency for incorrect denial and non-payment of claims. Analyzed claims to determine if they were paid using batch, claim and business rules edits, and what the paid amount should have been. As a result of our work, our client negotiated a settlement substantially less than the initial demand.
  • Supported a Part D plan with a review of the company's Part D submission processes that included reconciling multiple years of claims data to their PDE Submission files, conducting interviews with key staff to gain understanding of the company and their PBM's process as well as identifying trends and areas of risk.
  • Provided litigation support to a national Medicaid health plan in response to a subpoena issued by the Department of Justice. Worked with internal and external counsel to support the DOJ's subpoena requests, draft disclosure letters to and participate in calls with the US Attorney's office.
  • Provided support to a long term care service provider under investigation by the Department of Justice related to allegations of false claims and Anti-kickback statutes.
  • Assisted outside counsel of a large PDP contractor in conducting a comprehensive audit of all enrollment and disenrollment processes. The work also included reconciliation of CMS to plan eligibility records across different data systems. The issues arose from CMS received member complaints related to potentially fraudulent enrollment/disenrollment of members.
  • Assisted a Medicaid managed care plan to reconcile monthly risk adjusted capitation payments from the state.
  • Assisted a health plan to quantify the historical impact of mistaken payments related to a prudent layperson mandate. Recalculated correct payments that incorporated provider fee schedules, member benefit contract specifications and prompt pay interest.

Disputes

  • Performed analyses to identify and correct billing, claims processing and other health insurance reimbursement issues between providers and health plans. Matters include evaluation of contract reimbursement and damages related to various clauses in the parties' contracts.
  • Provided litigation support related to a dispute between a health plan and provider related to risk corridor payments associated with a capitated contract and out of network reimbursement payments under usual, reasonable and customary methodologies.
  • Assisted a Medicare Contractor in responding to a demand letter from CMS for inappropriate Medicare Secondary Payer (MSP) denials. Engagement included extensive analysis of eligibility data and claims redeterminations to reduce the ultimate payment.
  • Provided support for various pharmaceutical manufacturers related to class action litigation matters associated with pharmaceutical pricing and reimbursement issues. This included extensive work and analysis of manufacturer, wholesaler, pharmacy benefit manager, provider and health insurance data involved in the distribution and reimbursement of pharmaceutical drugs.
  • Supported external counsel in the development of scenario analyses and settlement strategies related to multi-jurisdictional litigation associated with false claims actions.
  • Provided litigation support to a medical device company related to the impact on Medicare reimbursement of Anti-kickback allegations.
  • Calculated the historical impact of mistaken calculation of prompt pay interest payments.