For counsel: in-house, outside & retained · Litigation & regulatory

The record says one thing. The algorithm said another.

Algorithmic-denial matters turn on a translation problem: what a utilization-management model predicted, against what the clinical record shows a person actually needed. The expert market offers data scientists who can explain the model and legal-nurse consultants who can read a chart. The disputed decisions often sit between them: skilled need, length of stay, discharge readiness, equipment necessity. Those are determinations rehabilitation clinicians and suppliers make and document every day. 5Q Health works in that space. Beyond litigation, 5Q supports counsel within or retained by healthcare organizations on the regulatory side, with governance reviews performed at counsel’s direction.

What 5Q brings to a matter

Clinical translation, governance standards, and the payment-policy record.

Clinical translation of model outputs
Length-of-stay predictions, therapy-utilization targets, and denial rationales read against functional assessments, standardized measures, and the documented clinical picture, in language a court can follow.
Governance-standard analysis
What reasonable oversight of a coverage algorithm requires under the NIST AI Risk Management Framework, ISO/IEC 42001, and Joint Commission’s Responsible Use of AI in Healthcare certification standards, and where a given program departs from it. AIGP-certified; methodology grounded in hands-on model development (MIT Applied Data Science Program).
CMS payment-policy context
Published, versioned analysis of the WISeR prior-authorization model, including the GAO determination that its notice is a rule and the first contractor corrective action plan, plus Medicare Advantage utilization-review rules and the prepayment-review machinery. On the record, dated, confidence-scored.
Record review at scale
Structured review of medical-necessity documentation across claim files with clinician-built rubrics: what the record established, what the algorithm credited, where they diverge.
Engagement types

Five ways counsel puts this to work.

Consulting expert

Non-testifying case support

Case theory, discovery strategy for algorithm and governance documents, and deposition preparation for medical-director and AI-oversight witnesses.

Discovery

Discovery review support

Clinical and governance review of produced materials (model documentation, review-board records, denial files), with structured summaries for the litigation team.

Reports

Report & testimony support

Functional-necessity and governance-standards analysis, independently or in support of retained testifying experts.

Education

Counsel education

Briefings and CLE-ready sessions on utilization-review algorithms, the WISeR model, and health-AI governance standards for practice groups.

Regulatory & compliance

Governance reviews at counsel’s direction

For in-house and outside counsel: AI vendor diligence, eligibility- and utilization-automation reviews, and HIPAA / 42 CFR Part 2 data-flow maps. Counsel decides whether and how privilege attaches. 5Q’s analysis informs counsel’s advice; it does not render legal opinions or compliance determinations.

Both sides of the table

More than a decade of front-line, person-centered clinical practice serving rural and under-resourced Medicaid populations in Illinois and Tennessee/Appalachia, then supplier-side practice in the FDA Class II medical device sector, during the years when automated denials expanded. I have written the documentation these systems review and fought the denials they produce. That experience is available to either side of a matter, and my analysis follows the record.

Independence & scope. Every inquiry is conflict-screened before any substantive discussion. Work is performed under counsel direction and appropriate confidentiality agreements. 5Q Health provides clinical and AI-governance subject-matter analysis. It is not legal advice; for legal opinions, 5Q works alongside counsel. Published 5Q analysis is versioned and dated; positions taken in that library are consistent with positions taken in engagements.

Secure channel. Routine inquiries go to contact@5qhealth.ai. Anything that needs a higher level of security or encryption (privileged communications, sealed or protected materials, protected health information, or matter files) goes only to 5qhealth@pm.me (Proton Mail: end-to-end encrypted between Proton users, and available through password-protected messages for everyone else). Send a short note first so the transfer method can be agreed.

Bring the record. We’ll read what the algorithm missed.

Inquiries: contact@5qhealth.ai with subject line “Counsel inquiry — [matter type].” Conflicts screened within the week. Privileged or protected materials: 5qhealth@pm.me only.

Start a conflict-screened conversation