Disputes & Investigations

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Payer Disputes, Compliance and Investigations

The complex disputes facing healthcare payers in today’s constantly evolving landscape involve the analysis of legal, regulatory and financial issues, and require an experienced expert with in- depth industry knowledge and experience.  We have worked with all types of payer entities including commercial, government, third-party administrators and pharmacy benefit managers, helping companies and their counsel quantify the potential impact of issues arising in the course of a dispute.

Our professionals include reimbursement specialists, clinicians, coders, technologists, accountants and statisticians.  We provide commercial litigation support, data analytics and expert testimony, contract compliance services a broad spectrum of industry issues, including:

  • Class Certification Defense
  • Contract Compliance
  • Out-of-Network/UCR Disputes
  • Federal and State Investigations
  • Medicare Advantage/Part D Compliance
  • Qui Tam Investigations
  • Medical Loss Ratio (MLR) and accounting investigations
  • Acquisition Disputes
  • Antitrust / Most Favored Nation Disputes

The Affordable Care Act (ACA) contains a very important provision that directly impacts the payer industry and its clients.  This provision is referred to as a minimum Medical Loss Ratio or ”MLR,”  a federal mandate that requires payers to expend a minimum percentage of premiums on health care services and quality improvement activities.  Many states have established their own MLR requirements or guidelines, which continue to be in effect in addition to the ACA regulations.

Click here to read our expert perspectives on Medical Loss Ratio (MLR)

  • Disputes, Compliance & Investigations Services for Healthcare Payers

  • Medicare Advantage & Medicare Part D - "Mock" Compliance Program Effectiveness and Program Audit Services


Our experts have the necessary experience and skillsets needed to address all MLR issues our clients may encounter, including: 

  • Allocating premium revenues for managed care organizations for carve-out services.
  • Identifying medical expenses (e.g., allocation of clinical administration, cost containment, substitution of services, incurred but not reported (IBNR) reserves, and allocation of fee-for-service (FFS) and capitation expenses).
  • Designing allocation methodologies of expenses related to quality improvement costs.
  • Analyzing FFS claims data, encounter data, capitated payments, and provider/vendor contracts in order to identify expenses that should be used in MLR calculations. 
  • Analyzing and quantifying rate-setting data for government state payer agencies.
  • Advising payers and/or their officers to address allegations of inaccurate reporting to government regulatory agencies.

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