Leveraging our capabilities and experience as one of the largest health care practices in the nation, our Managed Care and Payor Disputes team provides strategic, operational and litigation support to health care providers in all aspects of managed care and payor disputes. 

Unlike many other firms, we do not represent health insurance companies so that we are always strategically aligned with our health care provider clients on these important issues.

We represent the full range of health care providers, including for-profit and non-profit hospitals and health systems, hospital-based ancillary providers, air ambulance companies, behavioral health companies, as well as laboratories, pharmacies and medical device companies.

Our skill set in this space includes a thorough understanding of all of the laws that affect commercial reimbursement, such as the ACA, ERISA and federal /state “surprise billing” laws. We are also well-versed on the business side of commercial reimbursement from both the provider’s and payor’s perspective based on extensive experience on a national basis evaluating providers’ revenue cycle processes, participating in provider-payor contract negotiations, and assessing large data sets to identify trended issues and escalation opportunities. 

Our group of experienced health care trial attorneys are well-prepared to not only negotiate agreed resolutions of payor disputes but also bring them to final conclusion in court and arbitration when further action is required. 

We constantly monitor managed care cases and trends around the country and share this information with our clients in training sessions, webinars/seminars and publications on a regular basis, including through our Health Care Reimbursement and Payor Dispute newsletter and our annual Reimbursement Institute.

The major categories of our practice include:

Strategic, Contracting & Operational Support

  • In-network v. out-of-network strategies
  • Patient billing strategies and processes
  • Payor contract strategies and legal review, including value-based arrangements
  • Payor engagement audits/processes
  • In-house data analytics 
  • Legislative strategy and implementation
  • Deal support/managed care due diligence 

Payor Disputes

  • Out-of-network underpayments and misclassified emergency claims
  • COVID-19 reimbursement
  • Challenges to new payor medical/billing policies and protocols 
  • “Surprise Billing” arbitrations
  • Payor audits, recoupments, and offsets
  • General denials/other in-network disputes
  • Class actions
Related Capabilities
Health CareHealth Care LitigationReimbursement Audits & Disputes
Publications
All Publications
OIG’s New Medicare Advantage Program Compliance Guidance: What Providers Need to Know
Key Takeaways OIG’s new Medicare Advantage Industry Segment-Specific Compliance Program Guidance (MA ICPG) highlights major compliance risk areas and provides practical guidance for MA plans and other parties. Many provisions of this new guidance will impact health care providers participating in the MA program. As MA plans implement this guidance, providers may encounter new obligations from MA plans. This month, OIG released its long-awaited Medicare Advantage Industry Segment-Specific Compliance Program Guidance. In the 25 years since OIG last issued compliance program guidance in this area, the MA program has changed dramatically—in size, scope and complexity. And as the program has grown, so too has government scrutiny of many aspects of the MA program through audits, investigations, False Claims Act litigation and a growing body of
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Back to Backlog? Polsinelli Shareholders Share Insight on how Terminations of DAB Attorneys and Potential Removal of Administrative Law Judges May Impact Medicare Appeals
As the new administration continues its efforts to contract and streamline the federal government, recent developments at the U.S. Department of Health and Human Services (“HHS”) and the Department of Justice (“DOJ”) hint at a potential ballooning of the Medicare appeals backlog. 1. HHS Terminates at least 15 Departmental Appeals Board (“DAB”) Attorneys In 2017, approximately 31,000 appeals of Medicare claim denials sat waiting to be addressed and decided by the Medicare Appeals Council (“MAC”).1 While that number has decreased since then, about 11,000 appeals remain backlogged.2 The now-terminated DAB attorneys were hired within recent years to help reduce that backlog; each attorney was tasked with working on anywhere from 120 to 144 cases per year. Without them, an estimated 2,000 fewer appeals will
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