Mary Beth Edwards

Healthcare Billing, Payment, and Benefit Analysis:

• Mary Beth’s clients consist of large commercial health insurers, pharmacies, pharmacy benefit managers, providers, pharmaceutical companies, administrators of government programs (i.e., Medicaid Managed Care, Medicare, TRICARE contractors), third-party administrators, and other providers of healthcare services. She advises clients on a variety of operational, billing, and payment issues, including Medicare Risk Adjustment payments, out-of-network reimbursement, enrollment, billing, claim editing, contract analysis, and pricing. She has worked with over 100 billing and payment systems throughout the country.

Medicare Risk Adjustment:

• Mary Beth assists clients with issues involving the Medicare Risk Adjustment (MRA) payment methodology. Her work includes leading teams evaluating documentation for the diagnosis codes submitted and forensic data analytics of the beneficiary and provider populations. For matters involving disputed MRA payments, Mary Beth has modelled recalculated patient risk scores and quantified the financial impact, if any, of the alleged misconduct.

Pharmacy Billing Reviews and Investigations:

• Mary Beth has led various engagements related to assessment of compliance with contractual provisions between employer groups, payors, pharmacies, and Pharmacy Benefit Managers (PBMs) related to the pricing and administration of mail order and retail drug benefits. She has also led forensic reviews of inventory control and billing systems for a variety of pharmacies, including retail, compounding, and long-term care pharmacies.

False Claims Act Investigations:

• Mary Beth has assisted clients in various False Claims Act (FCA) investigations relating to alleged improper payments in the Medicare (Parts A, B, C, and D), Medicaid, and TRICARE programs. Her work involved analysis of internal controls, claims auditing, and forensic data analysis to evaluate the extent of the alleged misconduct. Mary Beth also develops financial exposure models quantifying the potential impact of the alleged misconduct.

Contract and Claims Payment Analysis:

• Lead expert on numerous payer-provider reimbursement disputes over various contract terms.
• Served as an expert witness in a matter involving an employer group suing its third-party administrator for failure to process claims accurately and provide adequate network discounts.
• Pricing and medical coding review of thousands of claims transactions in the TRICARE program in comparison to TMA regulations, Medicare guidance, and provider agreements.
• Analyzed reimbursement for worker’s compensation and automobile “personal injury protection”/ Med-pay payments according to various state regulations and various provider contracts.
• Involved in numerous lawsuits and investigations involving reimbursement of out-of-network providers under state regulations, contracts, and industry standards (e.g., Usual & Customary, UCR).
• Numerous matters involving damages related to alleged violation of various prompt pay/ ‘clean claim’ provisions in a variety of states

Class Certification:

• Served as a testifying, and consulting expert regarding class-wide allegations on issues involving alleged improper payments and coverage. In these matters, Mary Beth has analyzed hundreds of millions of records of transactional data across numerous computer platforms, both active and legacy systems. She has worked on class issues, including prompt payment, worker’s compensation, out-of-network payment, behavioral health coverage determinations, and automated-claims editing, among others.

Behavioral Health:

• Engagement leader in a nationwide class action alleging improper adverse benefit determinations for residential and outpatient behavioral health coverage. Evaluated coverage determination processes across the organization, reviewed electronic claims data, and clinical decision data as well as led a review of patient-specific case files.

Forensic Data Analysis:

• Mary Beth leads engagements involving the acquisition and forensic analysis of electronic business records from a variety of departmental functions. This work frequently involves the development of an analytical data repository that enables the analysis of disparate data, often from a multi-year time horizon, for purposes of performing financial analysis, auditing, or internal control reviews.