Elizabeth Hutchins

Elizabeth currently focuses her practice on healthcare disputes between payors and providers. She has extensive experience helping clients resolve disputes successfully through providing valuable analyses of the claims in dispute. She has led a number of payor/provider disputes related to the reimbursement/payment and adjudication of healthcare claims (both contracted and non-contracted), quantifying damages and focusing the dispute on the claims at-issue. She has worked on both affirmative and defensive matters for healthcare clients. Her work on healthcare dispute engagements includes the following services:

• Analyze healthcare claims/benefits data to understand at-issue claims to provide the client an understanding of the types of claims in dispute and identify any claims that could be excluded from case.
• Perform complex data analysis on full population of claims at-issue, including profiling the data and providing an assessment of exposure.
• Partner with statistical experts to develop statistical sampling plans/framework for cases that require a review of clinical documentation/medical records.
• Partner with billing/coding clinical team to perform review of claims documents/medical records for sampled claims for issues such as medical necessity, upcoding/down coding, and other claim-specific issues.
• Provide privileged consulting support including damage/exposure modeling, data management/operational support including preparation of claims data productions, requests for data from the client and opposing parties, and other ad hoc data-related analyses to support legal team.
• Provide expert witness report and testimony in arbitration/trial and at depositions.

Elizabeth has worked on a number of commercial litigation matters (consumer class actions, employment litigation, M&A disputes) and forensic accounting matters (tax controversy and revenue restatements). She has her MBA and CFE and CBIP certifications. She is active in the Chicago legal/business community.

Representative healthcare dispute engagements include the following:

• Contracted Reimbursement Rate Dispute Between Healthcare Payor and Provider: Provided privileged consulting and expert witness support on a contractual dispute in litigation in a $100 million dispute with 500 thousand services at-issue between a large commercial payor and provider of radiology services. Analyzed healthcare claims data including member cost share accumulations, quantified damages, and developed expert report.
• Contracted Rate Dispute Between a Government Administrative Contractor and a Class of Providers: Provided privileged consulting and expert witness support in a contract dispute between a Medicare/Medicaid administrative contractor and a class of physician providers. Re-priced professional claims against applicable Medicare fee schedule to calculate damages, accounted for various reductions for claims not at-issue, and accounted for impact of plan’s surplus bonus paid to providers on damages. Developed expert reports.
• Out-of-Network Reimbursement Rate Disputes Between Healthcare Payor and Provider: Provided privileged consulting and expert witness support for a large commercial plan in a multimillion-dollar dispute with a health system in a complex arbitration with seven populations at-issue including affirmative and defensive claims. Designed a statistical sampling plan which was adopted by the arbitrator. Developed analytical models to quantify fair market value for out-of-network claims. Contributed to the development of over 10 reports for two experts.
• Out-of-Network Reimbursement Rate Disputes Between Healthcare Payor and Provider: Provided privileged consulting and expert witness support on a multimillion-dollar dispute for a large national commercial payor and an out-of-network anesthesiology provider related to the reimbursement rate for professional services. Calculated damages based on fair market value using available benchmark data produced by the payor and provider. Engaged on two matters adverse to provider including affirmative and defensive claims. Developed expert reports.
• Out-of-Network Reimbursement Rate Disputes Between Healthcare Payor and Provider: Provided privileged consulting support on a more than $500 million dispute between a large commercial payor and a group of anesthesiology, radiology, emergency room, hospitalist claims to assess whether claims were subject to a large national arbitration or subject to federal or state statutes under the No Surprises Act. Calculated exposure.
• Upcoding Dispute: Provided privileged consulting support in an affirmative dispute between a large national commercial payor and provider group of emergency room physicians where the provider allegedly up coded emergency room claims. Provided statistical sampling plan agreed to by the parties for 700 thousand claims. Facilitated the review of the medical records and clinical documentation.
• False Claims Act Litigation Related to Discount Drug Program for a National Retail Pharmacy Chain: Provided privileged consulting and expert witness support to analyze hundreds of millions of transactional point-of-sale pharmacy records to quantify potential damages related to including price-matched transactions in the calculation of usual and customary charges.
• False Claims Act Litigation Related to Swapping under Anti-Kickback Statute: Built an analytical model using a mobile x-ray company’s accounting and payroll data to quantify the direct variable costs to provide services to support that the company’s pricing was at fair market value. Resulted in a favorable settlement with the HHS-OIG including the avoidance of a Corporate Integrity Agreement.