Complex multi-million-dollar billing dispute for large insurance plan provider

lab technician with test tubes

CRA was retained by counsel representing a large insurance plan provider to help resolve a complex multi-million-dollar billing dispute, between their client and a genetic cancer screening lab provider. Our client’s objective was to try to equitably resolve the dispute, recognizing that valuable services had been provided by the lab, even though some of those services had not been furnished and billed in accordance with the payer’s coverage and reimbursement policies. 

Our team worked extensively to estimate the value of services provided, despite observed deviations from established billing and performance protocols. Our work included normalizing and de-duping claims, mapping provider claim data to the payer’s line-level data, and a detailed review of the definitions of certain Current Procedural Terminology (CPT) codes. In addition, we analyzed historical denial rates and “crosswalks” between denied claims to adjudicated allowed amounts. 

Our analyses were crucial in helping our client successfully resolve this dispute, while also rebuilding and reaffirming the valued business relationship it had previously enjoyed with the provider.  

The CRA team was led by Vice Presidents Kristofer Swanson, Dr. Sean May, and Matthew List, with invaluable support from Patricia Peláez, Fei Tan, and Rachel Ott. 

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