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Provider and Payer Disputes

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BRG experts have worked on engagements for hospitals or health providers involved in disputes over reimbursement rates for both contracted and out-of-network services. The primary areas of dispute in these cases have involved:

  • Appropriate reimbursement (usual and customary) rates for non-contracted providers
  • Analysis and application of contractual clauses, such as clauses regarding reimbursement for stop-loss claims and high-cost items
  • Appropriateness of the denial of services as non-covered, medically unnecessary or provided without proper preauthorization or referral

In these matters, claims in dispute have included commercial, Medicare, and Medicaid members. In each case, the following primary tasks were performed:

  • Review of deposition testimony, contracts, contemporaneous correspondence regarding contract negotiations, and other documents produced through discovery
  • Assessment of opposing party’s damages claim and supporting documentation
  • Identification of “at issue” claims populations and selection of one or more statistically valid sample(s) of claims
  • Re-adjudication of sample claims and statistical extrapolation of results to the population(s) of “at issue” claims
  • Provision of other litigation support, such as advising during preparation for depositions, development of an expert report and provision of expert testimony, and settlement negotiations

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