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 and 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

Managed Care and Contracting Strategies

1.  Counsel various health care providers and related companies to address challenges, such as:

  • Evolving payor medical coverage policies
  • Dealing with reference-based pricing initiatives
  • Navigating ACA and ERISA laws
  • Use of hospital lien laws and related risks
  • Benefits, risks, and compliance issues for out-of-network providers

2.  Counsel various health care providers on managed care contracting issues, such as:

  • Key definitions affecting reimbursement
  • Who is obligated to pay and under what terms
  • Incorporating other documents by reference
  • Lease/rental networks
  • Silent PPO’s
  • Narrow and tiered networks
  • Coordination of benefits/late notice of correct payor
  • Escalation rights and requirements
  • Arbitration provisions
  • Audit rights
  • Recoupment and offset rights 

3.  Operational support for health care providers to map contract requirements for implementation by provider billing teams

  • Create payor-specific “playbooks”
  • Create state law “playbooks”
  • Chart administrative deadlines and appeals processes
  • Create template appeal letters

Managed Care Disputes

1.  In-Network Underpayments

  • Air Ambulance Company v. Health Plans – arbitration to enforce national contract rate for all affiliated plans
  • Hospital System v. Self-funded Employer Plan – lawsuit to enforce plan’s obligation to pay rates negotiated between hospitals and TPA on behalf of plan
  • Hospital Systems v. Health Plans – several matters challenging payors’ unilateral change in payment methodology through its provider manual updates
  • Hospital System v. Payor – arbitration to challenge payor’s denial of purported “incidental procedures”

2.  In-Network Denials

  • Hospital System v. Health Plan – series of over a dozen partially consolidated arbitrations around the country to challenge health plans’ medical necessity denial of claims

3.  Contract Interpretation Disputes

  • Hospital System v. Health Plan – dispute regarding applicable contract rate for new facility
  • Ancillary Provider v. Billing Vendor – dispute regarding contractual compliance and termination rights

4.  Payor Audits, Recoupments, and Offsets

  • Behavioral Health Company v. Health Plan – challenge to underpayments, denials and recoupment demand due to alleged documentation issues and alleged waiver of patient cost-sharing
  • Air Ambulance Company v. Health Plan – challenge to cross-plan offsetting practices by plan
  • ASC v. Health Plan – lawsuit to challenge attempted recoupment and offsetting due to payor’s unilateral change in payment methodology

5.  Out-of-Network Underpayments

  • Hospital System v. Health Plan - extensive litigation challenging underpayments for emergency medical services
  • Hospital System v. Health Plan - agreed arbitration establishing rate for emergency services for out-of-network rate agreement
  • Hospital v. Health Plan – arbitration of underpayments for emergency and authorized non-emergency specialty services
  • Air Ambulance Company v. Various Payors – multiple pending pre-litigation disputes challenging underpayments for emergency transportation services
  • Air Ambulance Company v. Health Plan – dispute arising from the plan’s failure to honor the patients’ assignments of benefits by paying claims directly to the patients instead of the provider.
  • Intraoperative Neuromonitoring Company v. Various Payors – challenges to payors for payment methodologies resulting in inadequate reimbursement.

6.  Out-of-Network Denials

  • Multiple pending pre-litigation disputes challenging denials on medical necessity grounds
  • Hospital System v. Health Plan – litigation to challenge medical necessity denials
  • Medical Device Company v. Various Payors – multiple challenges to payors for improper denial of claims due to investigational/experimental classification

7.  Out-of-Network Misclassification of Emergency Claims

  • Hospital System v. Health Plan – arbitration to challenge health plan’s improper designation of emergency claims as non-emergencies

8.  Defense of Patient Class Actions

  • Putative Patient Class v. Air Ambulance Company – defense of seven consolidated class actions in Colorado and three separately filed class actions in other states challenging “reasonableness” of air ambulance charges
  • Putative Patient Class v. Hospital System – defense of patient-initiated action regarding hospital practice to file hospital liens

9.  Challenge to CMS regulation

  • Tennessee Rural Physicians v. CMS – representation of 20+ physicians in federal court action challenging CMS regulation undermining statute to provide enhanced payments to physicians serving Medicaid patients in underserved communities

Legislative Strategy

1.  Counsel providers in various sectors regarding impact and implementation of proposed national and state legislation, such as:

  • Rate of reimbursement for out-of-network emergency services
  • “Surprise” billing
  • Abusive practices by payors, such as direct-pay-to-patient issues