Jennifer Wilson

Jennifer also has experience assisting clients with various compliance reviews. She has performed data analytics and repricing analyses on pharmacy and PBM billing and payment data to evaluate compliance with contracts along with federal and state regulations and guidance, including Medicare Part D and Medicaid. 

Jennifer is part of a team responsible for the data acquisition and analytics of large volumes of transactional data in a variety of industries including health insurance companies, pharmaceutical manufacturers, hospitals, and other healthcare facilities.

Jennifer’s professional experience includes:

• False Claims Act: Supported multiple disputes to determine potential financial impacts related to allegations that national and regional pharmacies submitted false claims to federal and state funded healthcare programs. Jennifer’s role involved loading, assimilating, and validating client claims data, as well as analyzing large-scale electronic data and assessing various pharmacy claims pricing methodologies. She was also responsible for interpreting and analyzing pharmacy-payor contracts and programmatically comparing the contract pricing terms to the actual prices submitted for reimbursement and development of self-disclosures and other expert reports.
• Controlled Substance Investigations: Supports an engagement related to a federal and state investigation evaluating a retail pharmacy’s dispensing patterns of opioids and other controlled substances. Jennifer’s role involves conducting a review of pharmacy claims data to identify trends and dispensing patterns correlated to sales of opioids and controlled substances, reviewing
• Independent Review Organization: Manages and supports an engagement where Ankura serves as the independent review organization for a national pharmacy benefits manager to identify improper payment and rejection of Medicaid secondary payer claims. As part of this engagement, Jennifer performs analyses to determine whether third-party liability claims received from state Medicaid programs, the VA, the DoD, and the IHS were processed correctly per payor contracts, state and federal regulations, industry standards, etc. Jennifer’s role involves pulling statistically valid samples of claims from each quarter and creating a comprehensive list of documentation required for review of the claims. Additionally, she developed a process for reviewing claims for accuracy and evaluating payor contracts, pricing terms, benefit plan designs, drug formularies, eligibility contracts, claims transaction details, etc. to determine if the sample population of claims was processed correctly. Jennifer is responsible for developing yearly reports for the OIG and providing recommendations to correct errors found in the third-party liability claims processing and adjudication systems.
• Internal Review of Payment Denial Patterns: Supports an engagement assisting a pharmacy client with an internal review of its claims denial history to understand the denial reasons and ways to resolve them. Jennifer manages and conducts a review of transactional payment data from multiple billing centers to identify payment denial trends and perform root cause analyses. 
• Healthcare Reimbursement, Pricing and Coding Disputes & Investigations: Assists clients in multiple payer-provider reimbursement disputes to assess potential financial impacts per their contracts. Jennifer analyzes issues such as compliance with administrative procedures (such as timely filing, appeals), pricing of services, enrollment/eligibility, member responsibility, coordination of benefits, and medical necessity. More specifically, her role involves loading, assimilating, and validating client claims data as well as analyzing large-scale electronic data and assessing claims pricing methodologies. She also develops industry benchmarks from publicly and privately available data sets for the purposes of evaluating damages related to alleged excessive billing practices and interpreting and analyzing payer-provider contracts and programmatically comparing the contract pricing terms to the actual payments made by the payer. Jennifer develops expert reports and prepares experts for testimony as well as critiquing and developing analyses of opposing expert reports, and helping counsel prepare for deposition of the opposing expert.