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The following is a sample list of cases in which the experts at Healthcare Litigation Support have assisted in resolving healthcare and health insurance litigation:

Plaintiff Cases:

1. A third party administrator (TPA) and a case management company were sued by the estate of an individual covered under a self-insured health policy, claiming that the deceased had suffered irremediable damage as a result of the health plan's delay in approval/coordination of stem-cell transplant benefits. We were asked to determine if there was deviance from industry standards and, if so, to what degree and were asked to review and comment on internal policy and procedures for both the TPA and the case management company. We assisted the attorneys in their development of both discovery requests and deposition issues.
2. A health insurance company was sued for misrepresentation and non-adherence to industry standards in its processing and payment of medical claims. We testified on both of those issues, and provided expert testimony on the marketing of the insurance product and the insurer's communications with the customers, both of which were material elements of this case.
3. A hospital CEO was terminated after he reported to the Board of Directors that the hospital's management company was possibly committing Medicare fraud. Subsequently, the former CEO was unable to find an equivalent position within the region's hospital community. We determined that the Board of Directors violated its own policies and procedures in the termination, and that they further released information that compromised the former CEO, and kept him from continuing in his career as a hospital administrator.
4. A health plan was sued for the wrongful death of a panel member resulting from delay in receiving needed care during a medical emergency. Plaintiffs argued that the HMO's Medicare risk program did not clearly communicate the fact that the member was permitted to self-refer to an emergency room for urgent care. The delay that resulted from this misunderstanding led directly to the death of that panel member.
5. A physician who failed to satisfactorily complete his surgical training was credentialed by a hospital and subsequently performed specialized surgery in the very areas in which he failed to complete his training. The physician was subsequently sued for malpractice. We testified as to the adherence (or lack thereof) by the hospital's Medical Staff Office and Credentialing Committee, using both its own and industry standards. We assisted the attorneys with the development of both discovery request and deposition issues.
6. A health plan was sued under the Federal False Claims Act by a 'whistle blower' for alleged misrepresentation on application(s) to obtain Medicare contract(s).
7. A Medicaid health plan was sued on claims of denial of service to a member due to errors in eligibility systems. We offered opinions in the following areas:
   a) how the health plan met or didn't meet its contractual obligations concerning notifying/updating its providers of member eligibility status
   b) how the provisions of the health plan contract that controlled this matter offered benefits to the member in contradiction to the written assertions
   c) how the health plan met or didn't meet industry standards
8. A class action suit was brought against a health insurance company for claimed irregularities in its calculation of deductibles and lifetime maximum benefits. We offered opinions and consultation in the following areas:
   a) how and where the practices parted from industry standards
   b) how the computerized claims calculation systems impacted the practices
9. A woman who was an HMO member was provided routine gynecological services by her primary care physician instead of being referred to a specialist and there was both a claimed delay in diagnoses and incorrect diagnosis/treatment, resulting in death. We provided consultation and testimony for the plaintiffs regarding the HMO benefits in the following areas:
   a) how the primary care capitation model affected the practice of the provider
   b) the history of the industry's change in mandating a benefit for a yearly "well woman" exam by a specialist
10. An orthopedic surgeon operated on the wrong foot of a patient. We analyzed the hospital's surgical process and error oversight provisions and testified as to its lack of adherence to Joint Commission on the Accreditation of Healthcare Facilities (JCAHO) standards.
11. A health plan was sued by an ancillary provider for underpayment of claims. We worked for the provider in analyzing the contractual and operational elements of the relationship. We analyzed both the industry standards and specific state regulatory issues affecting claims payments that applied to this matter.
12. We provided consulting and testimony for a case that involved a claimed delay in coordinating care on the part of a case management company, a third party administrator (TPA) and a public employer. We analyzed the claims and case management data and testified as to the lack of adherence to industry standards for both the TPA and the case management company. We also testified as to the lack of required oversight on the part of the employer.
13. A long-term care center was sued by the family of a resident who sustained several falls with resulting injuries while at the facility. Upon our review it was determined that, in addition to the falls, the staff failed to apply other basic standards of care for this dependent resident. The lack of comprehensively and timely assessment, monitoring, and intervention for this elderly resident resulted in our findings of significant weight loss, avoidable pressure sore development, and the improper use of both physical and chemical restraints. We provided affidavit, deposition and trial testimony in this case.

Defense Cases:

1. A health insurance company was sued for allegedly failing to properly handle and pay its portion of a claim that coordinated with Medicare. The insured was covered under a Medicare HMO. We testified as to the difference between Medicare Managed Care and 'regular' Medicare and provided testimony on the applicability of state regulations and the National Association of Insurance Commissioner's (NAIC) standards.
2. A national accounting firm was sued by one of its hospital audit clients for malpractice. We testified on two separate but related issues. The first was the billing and collection activities of the hospital. The second was the performance of the Board of Directors in fulfilling its responsibility to monitor and assess organizational processes and outcomes.
3. A health plan was sued by one of its contracting provider organizations for failure to adhere to the terms of its contract. We testified on a number of issues, including the risk sharing model, termination provisions and claims processing. We researched and testified on industry standards and on our own expert analysis of the facts.
4. A health plan member presented to his primary care physician with cardiac symptoms. He was diagnosed and treated by his physician. The member subsequently suffered complications and needed to be hospitalized, where he was treated by a cardiologist, among others, and did not survive his stay. Plaintiffs argued that the health plan's surplus-sharing model interfered with the primary care physician's openness to refer members to specialists, which in this case resulted in delay in treatment and death.
5. An insurance company was sued by a member for non-payment of benefits under a 'cancer policy' that had a provision for coordination with Medicare; however, the beneficiary was a member of a Medicare HMO. We offered consultation and opinions in the following areas:
   a) the structure of Medicare HMOs and their impact on the issues
   b) how the State regulations affected the claimed injuries
   c) how the National Association of Insurance Commissioners (NAIC) guidelines affected the claimed deviations
   d) how the assumptions and conclusions in the opposing expert's report failed to meet industry standards and were not supported by industry standards and NAIC guidelines
6. A public accounting firm was sued by its hospital client for malpractice following a significant financial loss by the hospital. We offered opinions and consultation in the following areas:
   a) how the delay in the updating of the hospital claims submission systems of the hospital were or were not material in the hospital's financial history
   b) how the Board of Directors did or did not act as within industry standards
   c) how the executive staff of the hospital did not act within industry standards
7. We were involved with two cases in which a physician executive search company was sued for actions on the part of a physician that it had secured for a hospital on a Locum Tenens contract. We testified in both instances regarding the credentialing and privileging requirements of both the contracting hospital and the search firm.
8. A hospital was sued as part of a malpractice claim against a general surgeon on a bariatric surgery case. We analyzed the process and oversight of the hospital medical staff office in terms of credentialing and privileging.

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