Managed Care

Deep Litigation Experience in Payer-Provider Disputes: We have represented clients across the country in some of the most contentious managed care litigation and arbitration. We routinely handle disputes over medical necessity, authorization, experimental exclusions, unbundling, chargemaster protection, and reimbursement calculations under stop-loss, DRG, and per diem provisions. Our team has a wealth of experience with affirmative litigation in which payers challenge fraudulent and abusive billing or seek recovery of overpayments, in both in- and out-of-network settings. We understand the strategies that work in this space and how to protect our clients’ rights under the NSA and state analogues, provider contracts, state insurance statutes, and ERISA.

Member and Plan Sponsor Disputes:  Our managed care practice includes the defense of individual and class actions by plan members challenging claim denials on a variety of grounds, from medical necessity and state coverage mandates to mental health parity requirements. We also regularly handle disputes in which plan sponsors allege benefit overpayments, improper ASO fees, and incorrect claims reporting in the context of stop-loss insurance.

Support for Evolving Care Delivery Models: We advise on shared-risk arrangements, contract design, network adequacy, and out-of-network disputes.

Integrated Insight Across Regulatory, Transactional & Litigation Needs: From credentialing and provider enrollment to termination disputes, we bring insight to every stage of the payer-provider relationship.