Case Studies: General Litigation Support
Third Party Administrator Payer Investigation and Litigation
Support
BlickenWolf was retained by counsel of a third party administrator
(TPA) of medical insurance plans. The TPA, which represented employees
of nearly 100 companies and governmental organizations of varying size,
was charged with seven counts of felony theft. The State contended
that the TPA straddled claim payments across different fiscal years
to avoid reaching cumulative claim amounts, which would disqualify
it from receiving bonus payments from the reinsurer. We assisted counsel
in building its defense beyond the analysis of discovery documentation,
including the creation of financial impact scenarios and industry cost
models. The results of our analysis culminated in our provision of
expert testimony that proved to be the backbone of the TPA’s defense.
The jury subsequently exonerated the TPA of all charges.
Academic Medical Institution Investigation
BlickenWolf was engaged by a major academic medical institution’s legal
counsel to perform a shadow audit of certain patients’ billing and
medical record documentation that were provided to the U.S. Attorney’s
Office in response to a subpoena that was issued to the provider.
We conducted extensive analyses of the client’s billing and medical
record documentation to determine the direction of the government’s
Grand Jury investigation and to provide plausible legal strategies
for the institution’s counsel.
Hospital System Emergency Department Investigation
BlickenWolf was engaged by a hospital system’s outside counsel to assist
in the investigation of potential False Claims Act violations. The
U.S. Attorney’s Office subpoenaed patient billing and medical record
documentation in connection with the allegations. We conducted extensive
analysis of the client’s billing and medical record documentation
to assess whether the provider intentionally submitted false claims
to governmental payers. Our analysis provided legal counsel with
strategies to defend against the potential violations.
