Healthcare

Clients draw on our expertise in competition issues involving the healthcare sector, including hospitals and insurance providers. Our staff and experts address allegations of:

• Predatory and discriminatory pricing
• Price fixing by physicians’ associations or hospitals
• Price fixing of healthcare workers’ wages
• Exclusionary practices
• Monopolization

In our analyses, we define relevant markets, assessing existing market power and determining the competitive effects of mergers and acquisitions as well as allegedly anticompetitive behavior involving:

• Hospital systems
• Outpatient care facilities
• Physician services
• Insurers

When healthcare organizations merge, complicated issues arise among patients, providers, and insurers. Such mergers involve complex empirical analyses to assess competitive effects, including questions related to bargaining, quality of care, risk-sharing, and efficiencies.

Our staff and experts have experience in a variety of reimbursement-related matters on issues of sampling, liability, and damages. These cases include private reimbursement disputes between payors and healthcare providers, as well as False Claims Act, Anti-Kickback Statute, and other government audit and contracting matters brought against healthcare providers.

Our experience includes:

• Complex statistical sampling from a large number of claims and extrapolation of sample results to assess liability and damages issues
• Reimbursement disputes between providers and payors, including analysis of alleged unnecessary treatment and upcoding, and estimation of damages
• Analysis of usual and customary reimbursement rates for out-of-network providers
• False Claims Act and government audit matters involving alleged overpayments in Medicare Fee-for-Service, Medicare Advantage, and Medicaid
• False Claims Act matters involving false advertising allegations
• Fair market value analysis of payments for products and services, per the Anti-Kickback Statute
• Government contracting matters related to the Affordable Care Act, including risk-adjustment, risk corridors, and reinsurance
• Waiver of patient coinsurance and co-payments

We partner with physicians and medical billing experts to assess and integrate their opinions of medical necessity and claims coding into our damages and liability analyses.

Cornerstone Research provides class certification analyses in a wide range of healthcare cases, including antitrust and competition, managed care contracting, coverage disputes, reimbursement practices, and disputes related to alleged “surcharge fees” and “surprise medical billing.” Clients also seek our expertise in class certification analyses for cases involving claims of product liability, misrepresentation, and false advertising pertaining to medical institutions and healthcare products. We have addressed questions of common proof and common impact as well as questions of ascertainability and numerosity.

In addressing these questions, we combine our extensive knowledge of the complexities and unique characteristics of the healthcare markets (including pricing and payment complexity, patient heterogeneity, and provider-payor interactions) and our expertise with advanced empirical and statistical techniques.

Our recent experience includes:

• Evaluation of alleged harm resulting from changes in the retiree healthcare benefits of a proposed class.
• Analysis of charges to a proposed class of uninsured emergency room patients, allegedly in excess of the “reasonable value” of the services provided.
• Assessment of ascertainability of the members of a proposed class and the alleged impact on patient cost sharing.

Clients rely on our decades of experience with complex cases requiring data management, integration, sampling, digitization, production, and analysis, including advanced empirical modeling and statistical techniques. Many healthcare matters involve analyzing large medical claims databases.

Cornerstone Research regularly analyzes databases containing hundreds of billions of records. We have the staff expertise and state-of-the-art, secure computing facilities to quickly and efficiently handle large volumes of sensitive healthcare data. This includes experience with data masking and anonymization as well as applying AI and machine learning to create structured data through supervised record linkage, resolving distinct entries to a common entity. We also have experience implementing state-of-the-art econometric techniques utilizing algorithmic methods.

Cornerstone Research’s expertise includes major price and claims databases, such as MarketScan, FAIR Health, and Medicare, as well as insurer-specific claims datasets, internal provider billing systems, Medicaid data, and other large discharge databases.