Mary Beth Edwards is the leader of Navigant’s payer/provider dispute, compliance and investigations market segment. She provides consulting and expert services relating to the payment and adjudication of healthcare services and benefits, often in the context of contractual or regulatory disputes or investigations. Edwards' experience includes working with payers (commercial and government-sponsored programs), providers (acute care providers, ancillary providers, pharmacies) and manufacturers. She has analyzed hundreds of different billing and claims processing platforms and evaluated hundreds of millions of claim transactions for all types of medical care including professional, facility, pharmacy, behavioral health, durable medical equipment, and a variety of ancillary services, including laboratory services.
In her work, Mary Beth is frequently retained to quantify the potential damages or exposure in the case. By way of example, she has performed damages calculations involving the quantification of alternative reimbursement based on various interpretations of terms in a contract (or application of a government fee schedule), a comparison of various industry reimbursement methods, or quantifying the impact of the application of clinical coding/editing guidelines. These assignments typically involve the analysis of millions of records of electronic claims/billing data, as well as other types of operational and financial data, in order to develop a sophisticated analytical model to calculate the financial exposure.
Representative engagements describing Mary Beth’s experience with the calculation of damages in complex payment disputes are as follows:
- Healthcare Reimbursement, Pricing and Coding Disputes & Investigations\For many of the nation’s largest commercial and government healthcare entities – including payors, providers and pharmacies – Mary Beth analyzed the detailed billing/claim transactions to evaluate how they were paid relative to provider agreements, medical guidelines, statutory requirements, and/or industry standards. She has analyzed over 100 different billing and claims processing platforms and evaluated hundreds of millions of claim transactions for all types of medical care including professional, facility, pharmacy, behavioral health, durable medical equipment and a variety of ancillary services.
Pharmacy Reviews and Investigations
- Mary Beth led various engagements related to assessment of compliance with contractual provisions between employer groups, payors and PBMs related to the pricing and administration of mail order and retail drug benefits.
Medical Payment and Contract Analysis
- Mary Beth served as the lead expert on numerous payer-provider reimbursement disputes over various contractual terms for professional, facility, behavioral health and pharmacy claims. The issues analyzed have included compliance with administrative procedures (timely filing, appeals), pricing of services, enrollment/eligibility, coordination of benefits, dual risk, etc.
- For various payer-provider disputes, Mary Beth developed a data warehouse to reconcile provider billing data with payor/government claim data to evaluate potential financial exposure under alleged contract/statutory violations.
Coding and Billing Reviews
- For numerous projects, Mary Beth led teams of certified coders, pharmacists and other clinical professionals in the review of medical records and other clinical criteria for various issues including ‘one day’ stays, home health services, bundling/incidental procedures, medical necessity, and various outpatient diagnostic services.
- Served as engagement leader of process control reviews of various payer business functions including internal audit, claims processing, medical management and provider contracting to identify any opportunities for improvement in policy documentation, regulatory compliance and/or compliance with provider contracts. Issues analyzed included medical record documentation, provider discounts, coverage determination, coordination of benefits and claims payment.