Payer Disputes & Reimbursements
Our ERISA, Managed Care Litigation, and Health Care Teams have in-depth knowledge to efficiently resolve payer disputes and reimbursement issues for clients. This niche practice offers impressive experience of more than 20 attorneys that is not found among many other law firms.
Our talented and strategic litigators enable us to steer matters through all forums of dispute resolution in order to successfully achieve our clients’ goals. Our team of seasoned lawyers is complemented by non-lawyer specialists with billing, coding, and coverage skills. Our unique proprietary case management system allows us to efficiently funnel and track large case volumes, while providing the highest level of client service and attention to detail. A large portion of our work in this area involves the representation of health care providers in disputes with commercial payers, where we have recovered millions of dollars for our clients.
How We Help
- Enforcing commercial insurer compliance with preferred provider arrangements, third-party network contracts, and treatment agreements.
- 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.
- Handling ERISA administrative claims and appeals challenging benefit denials.
- Pursuing Office of Personnel Management (OPM) and Freedom of Information Act (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, 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.
- 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.