Richard Merino

Richard Merino is a managing director in the Health Analytics Practice (HAP) at BRG. He is an experienced expert witness and specializes in litigation support, internal and external investigations, healthcare operations, and compliance advisory matters.

Mr. Merino has been accepted as an expert witness in federal and state civil and criminal divisions and arbitration tribunals. He has testified in matters involving managed care entities—including those with governmental contracts—hospital systems, laboratories, and pharmacy providers. His expert testimony has been at the forefront of major healthcare matters, including value-based care (VBC) arrangements, specialty pharmacy, utilization management, and clinical quality in connection with disputes between healthcare entities.

Mr. Merino has assessed contract compliance and quantified the financial impact of potential underpayments or overpayments related to those contractual provisions. He has also served as a consulting expert for providers in litigations, many of which involved disputes over claims payment, processing, or denials in connection with contractual terms between the parties. These disputes also addressed appropriate reimbursement levels for noncontracted entities and the concepts of usual, reasonable, and customary charges, as well as the use of Chargemaster price lists by hospital systems.

With more than twenty-five years of experience in operations, regulatory compliance, process improvement, and disputes within the healthcare industry, Mr. Merino focuses on Medicare and Medicaid plan sponsors, commercial managed care entities, hospital and provider practice organizations, pharmacy benefit managers, and other healthcare-related entities.

Mr. Merino has managed and directed experienced teams in preparation for and participation in numerous regulatory audits performed by governmental agencies, including the Centers for Medicare & Medicaid Services, state Medicaid departments, and the Office of Inspector General (OIG). He has conducted operational risk detection, management, and remediation activities on behalf of managed care and governmental health plans and has developed and executed numerous corrective action plans.

Mr. Merino has worked with and on behalf of health plan special investigations units (SIU) and assisted in the development of programmatic, data-driven processes to identify aberrant claims and billing patterns. He has advised plans on the processes to undertake in response to potentially fraudulent provider behavior. He has reviewed claims and other data from hospitals, physicians, labs, and drug entities for potential fraud, waste, or abuse situations.

Mr. Merino has led multiple engagements related to governmental enforcement actions, including those initiated by the OIG and Department of Justice, including allegations of fraud, non-compliance, and other enforcement actions.