Matthew Ryan

Matthew has more than 14 years of experience with disputes involving a variety of reimbursement and other related claims processing issues. His work often leverages the complex analysis of large volumes of records of electronic claims/billing data, as well as other types of operational and financial data, in order to develop sophisticated analytical models and financial calculations. Previously, he was a Director at Navigant Consulting.

Areas of Expertise

• Healthcare Benefits & Reimbursement: Assists clients with issues surrounding the operational procedures, IT systems, regulations and industry standards regarding the payment and administration of healthcare benefits related to all types of medical services and treatment settings.
• Complex Healthcare Data Analytics: Coordinates the identification, collection, and analysis of complex and electronic business records from a variety of departmental functions for disputes often involving voluminous datasets. Analysis often involves the aggregation of data across many disparate sources, the development of sophisticated data models to assess claims processing, editing, and payment, and the comparison of client data patterns to various industry standards and benchmarks.
• Damages/Financial Modeling: Develops assessments of potential financial damages arising from internal investigations, compliance reviews or commercial reimbursement disputes. Work often involves the development of various scenario-based assessments modeling exposure under a number of different contexts. Assists clients in such calculation of damages for use in initial case assessment, mediation, and expert testimony settings.

Representative Engagements

Out-of-Network Reimbursement Disputes

• Engagement lead for the support of a large national payor in its dispute with an out-of-network acute care hospital regarding allegations of improper reimbursement over a multi-year period, excessive billing, waiver of patient cost-sharing, overuse of emergency facilities, among other issues. Performed in-depth claims data analysis, review of payor, and hospital claims documentation, and market reimbursement benchmarking data to investigate issues, and assess potential damages. Supported expert witness in the development of several affirmative, and rebuttal expert reports, preparation for deposition, and trial testimony. Provided analytical support to legal team throughout multi-week trial.
• Engagement lead for the support of a large national payor in its dispute with an out-of-network physician management organization providing hospital-based anesthesiology, radiology, and emergency services regarding allegations of underpayment. Performed in-depth claims data analysis, review of payor, and hospital claims, and 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 the support of a large national payor in its dispute with several hospitals over the alleged improper application of contracted reimbursement rates over a multi-year period. Performed in-depth claims data analysis to assess potential exposure, and develop various financial models for the purposes of mediation.
• Engagement lead for numerous projects assisting payor clients with the investigation, analysis, and defense of alleged violations of various prompt payment standards. Such engagements involve the initial processing, and review of expansive disputed claims lists produced by the opposing party, the collection, and analysis of responsive data available to the payor, and the development of potential affirmative defenses, and potential mitigating factors for review.

Claims Processing/Editing Disputes

• Engagement lead for the support of a large national payor in its dispute with a hospital system regarding the application of proprietary, and industry claims processing edits, reimbursement bundling, medical necessity denials, and retroactive denial/retraction of reimbursement. Performed in-depth claims data analysis, review of payor, and hospital claims, and contract documentation, and industry research to investigate issues, and assess potential exposure. Supported expert witness in the development expert report summarizing observations.

Class Action Disputes

• • Engagement lead for the support of a large national payor in its defense of a member class action lawsuit regarding allegations of the improper denial of benefits for mental health, and substance abuse treatment. Provided analysis of data, and document regarding potential class members for the purposes of class certification review. Supported expert witness in the development of expert report, and preparation for deposition testimony.