AACG healthcare economists and statisticians have assisted counsel and healthcare institutions in a broad range of areas, including the following:

  • Antitrust and Mergers
  • False Claim Act (FCA)
  • Kickback and Qui Tam claims
  • Demographic projections of healthcare utilization
  • Off-label use of pharmaceuticals analyses
  • Intellectual property disputes related to healthcare technologies
  • Reimbursement disputes, including statistical sampling and benchmarking to comparable physicians, healthcare institutions and testing facilities

Our economists and statisticians are particularly adept at capturing and analyzing large volumes of data in order to model complex markets. For example, in the areas of Kickback claims and Reimbursement disputes, AACG has significant experience in developing refined benchmarking of client providers to comparable providers based on the national use cost reports, analysis of Medicare reimbursement databases (MedPAR, Carrier Statistical Analysis Files), and large-scale surveys collected by agencies of the U.S. Department of Health and Human Services (National Health Interview Survey, Medicare Current Beneficiary Survey). Where information is costly or time-consuming to obtain, we tend to design and adopt a sampling approach to ensure cost-effective results.

In the areas of Antirust/Mergers and Intellectual Property disputes, AACG understands how to analyze the competitive forces, and measure the market impact, associated with the entry or exit of participants in healthcare service and product markets. Further, AACG has extensive experience capturing associated cost and operations data needed to determine savings from a potential merger or to measure the marginal cost associated with increased product sales in an intellectual property case.

Representative Engagements

Kickbacks

  • In a dispute over alleged overbilling and kickbacks, our healthcare experts critiqued the sampling methodology of the expert retained by the DoJ and, separately, demonstrated that the chosen peer group of providers did not represent comparable practitioners.
  • In an alleged violation of the Anti-Kickback Statute, the DoJ alleged that Golden Living, a nursing home operator, had set up a “sham company” to profit from feeding services. An AACG healthcare expert demonstrated that the company in fact bore entrepreneurial risks and charged fair market prices, and further that the alleged Kickback mechanism was not functional.

Medicare and Medicaid

  • Our healthcare experts have assisted counsel for some of the largest healthcare networks in the US in numerous U.S. Department of Justice (DoJ) investigations of hospitals related to alleged charge manipulations to boost Medicare Outlier payments. We recalculated what Outlier payments would have been under alternative charge growth scenarios; demonstrated what fraction of above-average Outlier payments were due to patient mix, quality of care, and other facility or patient characteristics; and assessed clients’ ability to pay restitution.
  • The Centers for Medicare and Medicaid Services (CMS) retained one of our experts to develop a Monte Carlo simulation model of health status and medical expenditures and estimate the financial implications for Medicare and Medicaid of major medical breakthroughs.

Coding and Billing

  • Our healthcare professionals served as expert on coding and billing practices of flow cytometry procedures. We documented that the distribution of invoiced markers (antibodies) of a laboratory was consistent with that of comparable laboratories analyzing blood from patients with related ICD-9 codes.
  • AACG healthcare experts designed and implemented a stratified sampling approach to monitor billing and use of durable medical equipment.
  • Our statisticians implemented an advanced, powerful, stratified sampling approach to measuring billing inaccuracies and Accounts Receivable at a medical provider.

Mergers and Antitrust

  • In a series of merger-related engagements, AACG experts analyzed the share of the market serviced by the healthcare providers or insurers across the geographic and product market, determining where increased market concentration would occur and whether those market changes were likely to benefit or hurt consumers. AACG captured cost data to determine whether the proposed transactions would provide cost saving and other efficiencies that would benefit consumers.
  • In connection with a hospital expansion dispute, our healthcare professionals served as economic expert to project long-term healthcare utilization in a hospital’s catchment area, accounting for trends in demographics and medical technology.

Damages

  • In multiple cases, our healthcare professionals served as economic expert to assess lifetime lost earnings due to injury in a petition under the Vaccine Act.

Discrimination

  • Our healthcare experts analyzed workplace injury records to assist counsel to refute allegations of racial discrimination in exposure to workplace injury hazards.

Health and Disability Insurance

  • The U.S. Department of Labor (DOL) retained our healthcare professionals to document trends in the retiree health insurance liabilities of American companies. Separately, based on Form 5500 filings, we documented trends in self-insured group health plans for DOL, which forwarded our report to the U.S. Congress. We are currently studying healthcare subrogation practices and Multiple Employer Welfare Arrangements (MEWAs) for DOL. The Social Security Administration (SSA) retained one of our experts to develop a Monte Carlo simulation model of work and disability status and estimate the financial implications for Social Security’s Disability Insurance program of proposed increases in Social Security’s early retirement age.

Intellectual Property

  • In numerous intellectual property disputes related to healthcare products and pharmaceuticals, AACG analyzed the impact of an additional, alleged infringing, competitor on product prices sales, costs of production and profits. These analyses often required detailed analysis of the quantities and prices of competing products to determine not only market shares, but also which products competed with others and whether the allegedly infringing product competed with the plaintiff’s products. These analyses also call for detailed understanding and capture of production costs data, in order to determine profits and lost profits. AACG has the deep experience in economics, data analytics and corporate records and structures to work efficiently with corporate clients to collect the required records with a minimum of disruption, and then to analyze them based on rigorous economic models and econometrics.

Selected Publications