Lindsay Knutson

Lindsay Knutson is a director in the Health Analytics practice at Berkeley Research Group (BRG). She has worked with the independent monitor Mr. Stevens for more than five years, including senior roles in two independent monitoring projects. She supports testifying experts by conducting analysis of health plan and hospital/provider claims payment data and has provided expert testimony specific to fair-market-value dispute litigations. As a data analyst, she applies her expertise in data analytics and coding to engagements that involve health plan–hospital claims disputes using health plan or hospital paid claims data, as well as comparative commercial, Medicare, and Medicaid data, as a tool in evaluating reimbursement rate issues. Her credentials include:

• Certified Professional Coder CPC-A (No. 01451067), AAPC (formerly American Academy of Professional Coders)
• Licensed Attorney (No. 0386823), State of Minnesota

Compliance and Consulting

• Led external vendor validation of managed care plan’s timely access report and data submission for two annual reporting cycles on behalf of a California health p lan which was submitted to the California Department of Managed Healthcare (DMHC). Scope of work included reviewing compliance to survey methodology, testing data integrity, determining accuracy of measuring and reporting rates of compliance, and accessing reliability of the data submitted by the plan. Subsequently led the training of the health plan’s employees and monitored their results to ensure compliance going forward.
• Managed data analytics for monitoring engagement that included data migration investigation, standardization of data analytics reporting, and trending analytics using claims data. Used data trends to identify audit and payment risks.
• Led delegated entity audit that included utilization management, claims payment, and reporting validation to ensure compliance with corrective action plan. Utilized audit results to recommend process standardization, system enhancements, and training opportunities to improve compliance monitoring and results reporting. Used data trends to identify operational, system, and reporting issues. Investigated and provided solutions for identified issues.
• Managed monitoring engagements overseeing adherence to divestiture agreements between medical device manufacturers as required by Federal Trade Commission (FTC) consent agreements to deter the anticompetitive effects of mergers or acquisitions.
• Performed internal compliance audit on behalf of the board of directors of multistate substance abuse rehabilitation facilities focused on policies and procedures, documentation risks, credentialing practices, payor audits, and licensing and government regulatory compliance.
• Assisted with buyer-side due diligence audit of target company’s capitation arrangements and compliance with the Centers for Medicare and Medicaid Services’ (CMS) Medicare marketing guidelines.
• Developed model to calculate the fair market value of domestic and international healthcare professional consulting services using licensed provider compensation and global economic data for an international biotech company.
• Assisted with buy-side due diligence audits of air ambulance providers to identify potential billing and coding risks and compliance with industry standards.
• Developed capitation rates for payer/provider contract negotiation utilizing payor claims data, publicly available Medicare data sets, and industry information.

Litigation Support and Dispute Matters

• Oversees claims data/benchmarking analyses in reimbursement disputes between health insurance companies and providers, and between providers and their vendors. Such work includes inpatient and outpatient claims, including both the facility and professional components. Work includes analyzing commercial, Medicare, and Medicaid rates, contract compliance or interpretation, regulatory requirements such as prompt pay, fair-market reimbursement for out-of-network emergency, and post-stabilization claims.
• Led the development of methodology to determine the reasonable value of healthcare services in personal injury cases. Measured the reasonable value of costs for past and future medical care as outlined in life care plans and provider bills for more than one hundred personal injury matters.
• Oversaw the analysis of Patient Protection and Affordable Care Act (ACA), Medicare, and Medicaid coverage issues and collateral source issues for personal injury matters.
• Prepared multiple hospital peer benchmarking analyses utilizing California Office of Statewide Health Planning and Development (now California Department of Health Care Access and Information) hospital chargemaster and financial reporting data comparing rates of reimbursement, reasonableness of provider charges, and cost-to-charge ratios to assess whether hospitals’ charges and reimbursement rates were in line with market rates for the specific departments within the hospitals and geographies.
• Led the data analysis using publicly available state encounter data to evidence need in support of a successful certificate of need application for an ambulatory surgical center (ASC). Helped a hospital expand into a new state by demonstrating a need for patient services by performing detailed analyses by therapeutic area, patient age, gender, geography, and each specific type of service. Demonstrated that patients were traveling either to other areas within the state, or across the state, to receive needed services. The hearing officer, in support of her decision to award the client a certificate of need to open a new ASC, cited the analysis Ms. Knutson led.
• Performed a detailed analysis of Healthcare Cost Report Information System (HCRIS) annual report data to demonstrate the impact of graduate medical education funding on revised accreditation standards.
• Led the process of researching and analyzing network adequacy requirements to help a national health insurer through the bidding and appeals process for a federal request for proposal. Ms. Knutson’s extensive healthcare regulatory research coupled with data analytics helped the client win and defend a $40 billion contract.
• Analyzed health benefit plan documents and explanations of benefits to determine reasonableness of out-of-network reimbursement and adherence to plan coverage policies.