Our Services
Fountainhead has assisted its clients with several different types of services and analyses, from lost interest calculations to complex data modeling and analysis for multi-million dollar litigation. We have worked in a variety of contexts, including internal corporate investigations, pre-litigation inquiries, discovery, trial, settlement and mediation. Fountainhead provides its clients with objective analysis of the complex data surrounding disputes and investigations. Equipped with this valuable knowledge, Fountainhead's clients are able to make better, informed decisions.
The following shows some ways in which we have worked with our clients:
- Solutions to collect, merge and analyze complex data related to disputes or investigations
- Objective and comprehensive analysis of enrollment, billing and payment data sources
- Analysis of billing and payment arrangements in connection with payer, provider, broker, and group health plan disputes and investigations
- Data analysis related to breach of contract
- Analysis of claims accuracy and contract compliance
- Damages analysis and economic modeling
- Litigation services and eDiscovery
- Government health program disputes and investigations
- Medicare reimbursement reconciliations
- Out-of-network reimbursement
- Statistical sampling and analysis
- Forensic accounting and fraud investigations
- Expert testimony and reporting
- Six Sigma Process Improvement
Analysis of Systems and Processes Used to Determine FEHBP Membership
Engaged by counsel representing a health plan to assist in an internal investigation into FEHB Program rates. Project required gaining an intimate understanding of the processes and information systems used in setting the rates for multiple employer groups over a multi-year period. Interviewed numerous plan personnel, including actuaries, IT and employer group managers. Obtained the relevant data and system documentation to perform an in-depth analysis of how membership counts were determined within each data source. Applied this information to arrive at independent membership counts to compare with those used in annual rate proposals. Provided this information to counsel to use in a self-disclosure to the US Office of Personnel Management.
Health Insurance Claims Payment Dispute
Engaged by counsel representing a health plan in a payment dispute with an independent practice association (IPA) in which the IPA alleged underpayments on claims it submitted to the health plan. Identified and obtained relevant data sources from both parties in the dispute. Analyzed data involving more than 1 million claim lines and numerous other data and document sources to "reprice" claims per the terms of the contract and relevant fee schedules. Designed database and custom reports to integrate and analyze disparate data sources relevant to the issues in dispute.
State Attorney General Physician Directory Inquiry
Engaged by counsel for a health plan to assist in responding to a state attorney general inquiry into the accuracy of the health plan's physician directory. Obtained relevant data from the health plan, analyzed and reported on the claims submitted by the physicians identified by the attorney general's office.
Healthcare Provider Payment Dispute
Engaged by counsel for a health plan in a payment dispute with a provider. Identified and obtained the data related to the claims submitted by the provider to the health plan. Analyzed and reported on these data to allow the health plan to identify how they had actually paid on the claims submitted by this provider.
Provider Dispute with CMS Program Safeguard Contractor
Engaged by counsel representing a provider in a dispute with a CMS program safeguard contractor (PSC). Reviewed the statistical sampling and analysis performed by the PSC and advised client on its strengths and weaknesses.
Self-Disclosure to CMS
Engaged by counsel for health plan conducting an internal investigation as part of a self-disclosure to Medicare. Identified and obtained claims and payment data (including raw CMS payment data) from third-party billing agent and from the health plan. Reconciled claims and payment data to identify discrepancies in the amounts billed and paid. Reported results to in-house counsel for inclusion in self-disclosure to CMS.
Coordination of Benefits for Pharmacy Claims
Hired by counsel for health plan performing an internal investigation regarding the coordination of benefits for pharmacy claims. Obtained data related to pharmacy claims and "readjudicated" claims based on the coordination of benefits. Worked with in-house counsel to develop internal processes to coordinate benefits on future claims.
FEHBP Rate Audits
Engaged by counsel for health plan responding to multiple FEHBP rate audits conducted by the Office of Personnel Management Office of Inspector General. Provided forensic accounting support for the issues raised by the OIG.
Insurance Brokerage Disputes
Engaged by counsel for health plan involved in disputes with its insurance brokers. Identified and obtained data from both parties in the dispute and reconciled the amounts billed and paid. Reported results and provided analytical support at settlement conferences.
Provider Group Payment Dispute
Engaged by counsel for health plan involved in payment dispute with one of its provider groups. Identified and obtained data and documents related to the claims submitted by the provider group to the health plan. Reconciled amounts billed with amounts paid and provided analytical assistance to counsel at mediation. Also provided traditional litigation support, including document scanning and Bates numbering, to counsel in responding to discovery requests for data and documents.
State Attorney General Inquiry into Premium Rates
Engaged by counsel for a health plan responding to a state attorney general's inquiry into premium rates charged to a particular subscriber group. Assisted counsel in analyzing proof tables and charts associated with the investigation.
Medical Transportation Provider Dispute
Engaged by counsel for a health plan involved in a dispute with one of its medical transportation providers. Named as an expert in statistical sampling and analysis.
FEHBP Underpayment Calculations
Engaged by counsel to numerous health plans to calculate any unpaid premiums due the health plans by OPM pursuant to the plans' participation in the FEHB Program. Analyzed enrollment and payment data to calculate the amounts payable to the health plan and compared this to the amounts paid. Performed statistical sampling and analysis of enrollment forms to corroborate the calculation of unpaid premiums. Designated as an expert in FEHBP underpayment calculations. Fountainhead's data analysis and calculations formed the basis for the recovery of over $250 million in unpaid premiums for health plans.
Case Studies
Health Plan Client (pdf)
Provider group alleges large Health Plan underpayments; however, Fountainhead's objective analysis reveals net overpayments.
Reconciliation of Medicare Claims (pdf)
An HMO suspected that it was overpaid by CMS and requested a detailed, objective analysis to quantify such payments. As a byproduct
of this investigation, Fountainhead’s analysis also identified specific claims that CMS never received and/or paid.
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