Kaelan Nagle

Kaelan’s experience includes engagements focusing on performing complex data analysis for healthcare payers, providers, and their legal counsel to assess and quantify damages related to payment and adjudication of healthcare services and benefits. He has extensive experience assisting clients with disputes related to reimbursement, claims processing issues, and Medicare Advantage investigations.

Kaelan’s professional experience includes:

Areas of Expertise

• Medicare Advantage: Kaelan has extensive experience performing privileged consulting for Medicare Advantage plans related to investigations into the accuracy of their risk adjustment data submissions. He has managed project teams and directed the collection, processing, and complex analysis of risk adjustment data in support of Medicare Advantage plans’ assessment of their risk adjustment practices. Kaelan also has a deep knowledge of the Medicare Advantage payment model and has developed programs and processes to evaluate payment impact for his clients.
• Healthcare Damages Disputes: Kaelan has experience with several lawsuits and investigations involving out of network reimbursements, contracts, class actions, and industry standards (e.g., UCR).
• Data Analysis: Kaelan has extensive experience with data management, data analysis, and data mining applied in a wide variety of investigations and litigation matters. He has coordinated the identification, collection, staging, and analysis of several types of business records and has developed expertise in accepting, normalizing, and analyzing large, complex data sources.

Representative Engagements

Medicare Advantage

• Supported a large national Medicare Advantage payor related to investigations of the accuracy of risk adjustment data submissions including the review of medical records for adequate documentation as well as proper filtering of RAPS submissions to CMS. Collected and analyzed hundreds of millions of records from relevant claims, encounter, and risk adjustment data systems.
• Engagement lead for several matters assisting both regional and national Medicare Advantage payors investigations into home health vendor coding practices. Supported the payors’ investigations into fraudulent coding practices through the collection and analysis of risk adjustment data as well as patient charts for medical record review.
• Assisted a large national Medicare Advantage payor in an effort to apply their risk adjustment submission filtering across all recently acquired Medicare Advantage plans. Collected all relevant risk adjustment data and applied filter criteria to identify conditions and corresponding CMS overpayments for submissions not meeting filter criteria.

Out of Network Reimbursement Disputes

• Engagement lead for a large national payor in its dispute with out of network free standing emergency centers and their associated physician groups. Performed in-depth claims data analysis of payor, hospital, and physician claims. Reviewed contract documentation and market reimbursement benchmarking data to assess potential exposure and develop various exposure models for the purposes of mediation.

Contracted Reimbursement Disputes

• Engagement lead for a large national payor over a contractual dispute with an analytics coding vendor related to incremental Medicare Advantage reimbursement. Performed complex data analyses to model several damage scenarios for the purposes of mediation.

Class Action Litigations

• Supported numerous Fortune 500 healthcare payers’ quantification of exposure to member class action lawsuits surrounding the insurer’s implementation of ACA. Managed the collection, processing, and analysis of healthcare member, claim, and provider data in a SQL environment. Assisted in the strategy of quantifying exposure figures and carried out complex programs to analyze and report findings.

Pharmacy Benefit Management

• Led a privileged consulting team for an engagement related to the calculation of damages in a dispute between a national pharmacy benefit manager and their clients regarding compliance with contractual provisions related to the pricing and administration of drug benefits.

Overdraft Fee Analysis

• Supported several financial institutions through class action litigations and Consumer Financial Protection Bureau (CFPB) regulatory investigations. Plaintiff classes and regulatory matters consisted of a significant number of bank customers and allegations including improper overdraft fee assessments on consumer accounts. Kaelan has managed data collection, data assessment, data productions, database development, and programmatic analyses of data for financial purposes. He has supported the preparation of numerous financial reports for legal counsel including the assessment of alternative scenarios for sequencing of transactions and potential financial exposure. Kaelan has assisted in the preparation of expert reports regarding defense data analyses and issues with plaintiff expert analyses.