Managed Care, Payer Disputes and Reimbursement
Under the leadership of Caroline English, our ERISA and Managed Care Team draws experience from the firm’s leading Health Care and Complex Litigation practice groups to provide both a deep and broad understanding of the industry and the know-how to get payer relationship issues resolved.
This is a niche practice offering impressive experience of more than 20 attorneys that is not found in most law firms. We operate at the intersection of managed care, revenue cycle, and provider/payer relationships. Our substantive experience runs the gamut from ERISA, ACA, COBRA, FEHB, HIPAA, TRICARE, state insurance laws, Medicare Advantage, and the Medicare Secondary Payer Act, to federal and state health care regulatory law. And we handle everything involved, at every stage, including contract negotiations, regulatory and compliance issues, administrative appeals, litigations, and settlement negotiations.
Additionally, our proprietary case management system developed specifically for this practice allows us to funnel and track large case volumes with efficiency, while providing the highest level of client service and attention to detail.
What We Do
A large portion of our work in this area involves the representation of health care providers in disputes with commercial payers, where we have been entrusted by our clients to resolve disputes totaling hundreds of millions of dollars. Our clients—dialysis providers, hospitals, clinical laboratories, pharmacies, ambulatory surgery centers, physician practices, medical device companies, urgent care centers, and specialty health care providers—rely on us for cutting-edge strategic advice and insight and have confidence that we can resolve their most pressing and complex payer disputes.
The matters we regularly handle include out-of-network reimbursement disputes, managed care contracting disputes, payer audits and investigations, federal preemption issues, coverage disputes, coordination of benefits issues, network and preferred provider disputes, single patient agreement breaches, repricer challenges, “usual, customary, and reasonable” calculations, and recoupment demands.
We routinely handle administrative claims and appeals under ERISA, as well as through the FEHB/Office of Personnel Management, the TRICARE program, and pursuant to state-law governed benefit plans. In court, we pursue both provider-direct claims and ERISA assignee-based claims through trial and appeal, if necessary. We recently prevailed in a case for one of our clients in which we asserted ERISA claims for fiduciary breaches and benefits, and ultimately obtained reimbursement at nearly 100% of billed charges, plus an award of attorneys’ fees.
How We Help
Our recent engagements on behalf of health care providers have included:
- Enforcing commercial insurer compliance with preferred provider arrangements, third-party network contracts, and treatment agreements.
- Advising on ACA health plan exchanges, including eligibility and enrollment, plan options and benefits, rights and obligations under the ACA, and the intersection of ACA requirements with other federal and state law requirements; and litigating ACA violations.
- Challenging commercial payers who violate the MSP Act and other coordination of benefits rules, including litigation of MSP Act discrimination claims.
- Handling COBRA disputes with employers over notice issues, failure to provide continuation coverage, and disability extensions.
- Challenging, appealing, and litigating TRICARE program payment determinations.
- Handling ERISA administrative claims and appeals challenging benefit denials.
- Pursuing OPM and FOIA claims with respect to FEHB Plan disputes.
- Negotiating with plan sponsors with respect to alleged unlawful plan terms.
- Challenging audit findings, overpayment demands, and recoupment actions issued by third-party administrators, pharmacy benefit managers, insurers, and health plans.
- Representing providers in disputes with large insurers, including terminations of provider agreements.
- Challenging plan fiduciaries for failure to follow proper claims and appeals procedures.
- Litigating ERISA preemption defenses.
- Counseling providers on out-of-network “usual, customary, and reasonable” litigation.
- Drafting insurance verification, intake, and assignment of benefits documentation.
- Representing out-of-network providers in reimbursement disputes with self-insured and insured health plans.
- Advising clients through issues related to overpayments associated with Medicare, Medicaid, and other government payers.
- Handling Medicare Advantage plan claims and appeals and advising on rights under Medicare Advantage regulations.
- Advising on Medicare Parts A and B eligibility, enrollment, and entitlement issues, including retroactive entitlement determinations.
Our group boasts a roster of talented Litigators whose strategic capabilities enable us to steer matters through all forums of dispute resolution throughout the country in order to successfully achieve our clients’ goals. Our experienced Health Care attorneys are adept at tackling the regulatory, compliance, reimbursement, coding and coverage issues spanning the health care sector. The team is complemented by non-lawyer specialists with expertise in project management, billing, coding, and the highest levels of client service.