William Downs

Areas of Expertise

• Healthcare and Managed Care Disputes: Assists clients and counsel on matters involving healthcare payors and healthcare providers regarding out-of-network pricing, contract disputes, statistical analysis of claim payments, stop loss calculations, billing fraud, clinical coding disputes, mental health parity, prompt payment disputes, lab processing, and consumer class actions.
• Pharmacy Disputes: Assists clients and counsel on matters involving usual and customary pricing disputes, government investigations into pharmacies, class actions, red flag analysis, prescribing patterns for regulatory disputes, and other complex assessments of pharmacy transaction data.
• Life Science Disputes: Assists clients and counsel with medical device and pharmaceutical product liablity litigation as well as billing and clinical coding disputes between payors and providers involving medical devices.
• Commercial Insurance Disputes: Assists policyholders, insurers, corporations, and their counsel with insurance allocations, the estimation of mass torts and product liabilities, insurance coverage analysis, retrospective premium disputes, and the development and implementation of insurance settlements and coverage in place agreements. These engagements have involved liability related to medical devices, pharmaceutical products, abuse, environmental pollution, PFAS, welding rods, and construction defects.

Representative Engagements

• False Claims Act Litigation Related to Pharmacy Drug Pricing: Assisted a retail pharmacy in a dispute with a healthcare insurer over the application of “usual and customary” pricing terms on the amounts charged for certain prescription medications. This engagement included preparation of data analytics using prescription drug transaction data, analysis of drug price formularies, developing multiple exposure and damages models, assisting with the preparation of affirmative and rebuttal expert reports, assisting counsel with preparation for depositions, and preparation for multiple arbitration hearings.
• Out-of-Network Reimbursement Rate Dispute: Assisted healthcare insurers in multiple disputes with out-of-network providers regarding allegations of These matters have involved disputes over emergency services as well as non-emergency claims. Work on these matters has included preparing claim data analytics, statutory rate analysis, categorization of out-of-network coverage terms in member plans, auditing out-of-network payment methodologies, and preparing market-price benchmarking analysis to determine potential exposure and develop damages models for mediation, settlement, and trial. These engagements include developing and analyzing random samples of claims and health plans, assisting with the preparation of expert reports, evaluating the analysis of opposing experts, and assisting with the preparation of rebuttal expert reports.
• Pharmacy Consumer Class Action: Assisted a retail pharmacy involved in a consumer class action regarding the impact of the application of “usual and customary” pricing terms on the amounts charged for certain prescription medications. This engagement included preparation of data analytics using prescription drug transaction data, analysis of drug price formularies, developing multiple exposure and damages models, assisting with the preparation of expert reports, and assisting counsel with preparation for depositions.
• Contracted Rate Dispute Between Health Insurer and Provider: Assisted a healthcare payor in a dispute with a healthcare provider over allegations of the improper application of contracted rates. Analyzed contract provisions and industry regulations related to line-item denials and bundled billing. Prepared exposure models, assisted with the preparation of expert reports, and evaluated analysis prepared by opposing experts.
• Affirmative Fraud Dispute: Assisted a health insurer in an affirmative action against a health care provider for alleged breach of contract related to the funding source of certain member premium payments. Work on this matter included developing a methodology to identify at-issue members, payments made by the health insurer for those members, and premiums collected by the health insurer for those members. The analysis was included in an expert report that was filed in the litigation.
• Opioid Litigation: Assisted with data analytics of pharmacy transaction data, prescription drug monitoring program data, and state prescription drug databases for the national opioid litigation.
• Government Investigation into Pharmacy Pricing: Provided expert testimony for a retail pharmacy at an administrative hearing with a state Medicare agency over the impact of prescription discount card prices on “usual and customary” pricing for Medicare transactions. Work on this matter included preparing an analysis of potentially at issue transactions, calculating alternative pricing models, and presenting the analysis at the hearing.
• Medical Device Liability: Assisted a medical device manufacturer with the estimation of future filings of bodily injury claims related to a recalled medical device. Work on this matter included compiling sales data to identify the potentially exposed population, using historical device revision data from the client and from third party reporting to develop a range of potential revision rates, and using historical claims data to develop criteria for the propensity for a potential claimant to sue.
• Insurance Allocation and Claim Disputes: Retained as an expert witness and privileged consulting support on dozens of insurance allocation and claim valuation disputes involving bodily injury and property damage claims. Work on these matters has involved the compilation and assessment of historical claims and insurance data, preparing dynamic insurance allocations under various coverage approaches and valuation methodologies, authoring expert reports, providing deposition, and trial testimony.