Matters
- Represented national health system in breach of contract matter against a regional health plan regarding the plan’s refusal to pay services subjected to contractual carve-out rates
- Represented national health system in breach of contract matter against a rental network regarding reduction of reimbursement through line-item denials
- Represented regional hospital in breach of contract matter regarding 340B-based recoupments, DRG downgrades and E/M downcoding
- Represented national health system in breach of contract matter against a national health plan regarding interpretation of “lesser of” language
- Represented regional health system against a regional health plan in a breach of contract matter regarding systemic withholdings of reimbursement based on alleged mutual mistake and impossibility
- Represented regional renal services provider in a breach of contract matter against a national health plan regarding recoupments based on interpretation of the contract’s referenced-based pricing lanaguge
- Advised and counseled an academic medical center through a renegotiation of a provider agreement and out-of-network strategies against a national health plan
- Advised a clinically integrated network on pre-litigation strategies regarding a chargemaster-based recoupment attempt by a national health plan
- Advised a regional health system on best practices in contracting and revenue cycle strategies
- Represented a regional behavioral health entity against a regional health plan regarding denials of managed Medicaid reimbursement
- Negotiated a managed care contract and counseled on out-of-network strategies on behalf of a regional health system against a national health plan
- Represented medical device company in the overturn of denials by numerous national and regional administrators of Medicare Advantage plans.
- Represented a clinically-integrated network through a renegotiation of a provider agreement with a national health plan
- Counseled an academic health system in pre-litigation challenges of various payor policies aimed at reducing contractual reimbursement and increasing the system’s administrative burden
- Counseled a national health system in challenging an E/M downcoding payor policy
- Represented a regional health system in challenging a regional health plan’s readmission policy
- Advised a national health system in operational and revenue cycle strategies to challenge short-stay Medicare Advantage inpatient stays
- Advised a local infusion center on revenue cycle strategies to increase reimbursement from health plans
- Represented a national health system against a national health plan regarding a chargemaster dispute
- Represented an academic medical center in a breach of contract action against a health plan administering Medicaid and Exchange health plans to challenge line-item denials
- Successfully obtained waiver of applicability of a healthcare payer’s avoidable readmission policy to community hospital’s commercial and Medicare claims.
- Successfully obtained back-pay of enhanced primary care physician fees from national managed Medicaid administrator for regional physician group.
- Represented out-of-network behavioral health company on recoupment and direct pay-to-patient issues against a healthcare payer.
- Successfully settled in bulk over 250 individual denied or underpaid patient claims on behalf of a national health system against a regional health plan without escalating to litigation
- Represented a national health system in a breach of contract action against a national health plan regarding over 100 underpaid and denied patient claims
- Represented a regional behavioral health clinic in a breach of contract action against a regional health plan regarding the delay in payment of clean claims
- Counseled critical access hospital in developing an out-of-network strategy.
- Represented national emergency physician provider in challenging several payers’ E/M downcoding policies.
- Represented skilled nursing facility in contract dispute with healthcare payor regarding denials, underpayments and recoupments.
- Represented hospital in challenging the application of a national payer’s Sepsis-3 clinical policy.
- Represented a national health system in an ERISA action against a self-insured plan and its TPA to obtain benefits for cancer treatment
- Represented medical device company on a national basis in challenging medical coverage policies labeling FDA-approved device as “experimental or investigational.”
- Represented eleven hospitals in Tennessee against a commercial insurer for underpaying thousands of out-of-network claims for emergency services.
- Represented intraoperative neuromonitoring company on a national basis in challenging medical coverage policies.
- Represented hospitals part of national system in a series of arbitrations around the country in disputes against a large commercial insurer for underpaying hundreds of claims related to medical necessity.
