United States, ex rel. Dr. Susan Nedza v. American Imaging Management, Inc., et al.

Analysis Group was retained on behalf of Anthem and its affiliate American Imaging Management (AIM), the defendants in a false claims action brought by a relator on behalf of the federal government. The relator claimed that the defendants used AIM to review and deny Medicare beneficiaries’ pre-authorization requests that allegedly should have been approved, thereby forcing patients to either pay out-of-pocket prices or forgo the procedure. The plaintiffs alleged that, as a result, (1) the government paid for coverage that the Medicare beneficiaries did not receive; (2) the beneficiaries received less medical care than they were legally entitled to; and (3) the beneficiaries suffered delay and denial of medical procedures, increased financial costs, and/or inferior medical care.

Managing Principals Rebecca Kirk Fair and Mark A. Gustafson and Manager Anastasia Bogdanova led an Analysis Group team that evaluated AIM’s benefit management models across numerous health plans and years. The team reviewed both documents and data to determine the parameters of various benefit models and the time periods and clients to which each benefit model was relevant. Their analyses included statistical comparisons of denial rates among benefit models and across time, visualizations of changes in denial rates across time for different types of services, and development of an exposure model that categorized exposure by benefit model, client, and time period.

The team’s quantification of authorization patterns during the relevant period contributed to a favorable settlement for the defendants.