Authors
Over the past ten years, 7,352 qui tam cases have been filed, and 4,978 (68%) of these have been medical qui tam cases. Over the same time period, recoveries on medical qui tam cases have totaled over $21.1 billion.[1] Litigating medical qui tam and False Claims Act cases usually requires the help of damages experts with experience and capabilities many forensic economists lack. When choosing damages experts for a qui tam case, it helps to understand the skill sets required to calculate damages at the intersection of medical, legal, and analytical issues.
Medical Claims Experience
Medical claims data come in many forms. Damages experts may need to link medical billing and payment data, medical records, surgery logs, and more. Linking these documents and data to tell a coherent story is often more important and more difficult than the actual damage calculation. Damages experts should know the different code sets including Common Procedural Terminology (CPT), Healthcare Common Procedural Coding System (HCPCS), Diagnosis Related Groups (DRG), International Classification of Diseases (ICD), and National Drug Codes (NDC). Qui Tam cases covering long time periods may involve several versions of these code sets, so knowledge of both current and past codes may be required.
RPC has extensive experience managing and analyzing medical claims data. We have experience building databases from paper or PDF records and experience converting raw claims and payment data (ASCII X-12 837 and 835 files) into usable databases. We have the IT infrastructure to store and process large databases,
RPC has qualified staff in economics, business administration, health policy, and data analysis. Our team includes nurse consultants, medical coders, and physicians in many specialties. RPC’s understanding of medical claims data was developed through decades of experience with medical qui tam cases, payment disputes, hospital/physician disputes, and other healthcare litigation.
Legal Understanding and Experience
Experienced medical qui tam experts offer more than number-crunching. Besides the damage calculation itself, RPC’s team can help draft discovery requests, select the most appropriate statistical analysis, and provide experienced testimony and demonstratives which are accessible to judges and juries.
Most medical qui tam cases involve medical billing and treatment records with Personal Health Information (“PHI”) as defined by HIPAA. RPC has secure systems and privacy and security policies. Staff are trained annually. We have Business Associate Agreements drafted by a national health law firm. We carefully observe HIPAA regulations with electronic and paper records from receipt through destruction at the end of the case.
RPC has experience in medical qui tam and False Claims Act cases involving hospitals, physicians, surgical implants, and durable medical equipment. Our testifying experts have been accepted as experts for both plaintiff and defense attorneys in federal courts and before state courts and administrative agencies in over 25 states.
For additional information on RPC, or to discuss a case, contact Brian Piper, PhD or Angela VanDerwerken, PhD
[1] US Department of Justice, Civil Division. Fraud Statistics – Overview: October 1, 1986 – September 30, 2021. https://www.rpcconsulting.com/wp-content/uploads/2022/03/fy2021_statistics_0.pdf
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