Payer Dispute and Managed Care Litigation

Holland & Knight's healthcare attorneys have more than 50 years of experience working with providers – including hospitals, health systems, ambulatory surgical centers (ASCs), physician practices, behavioral health providers, medical service organizations (MSOs), dental service organizations (DSOs), dental practices and many others. We understand the nuanced relationships between providers and payers.

Our healthcare attorneys regularly represent healthcare providers in disputes with health insurance payers, including managed care organizations (MCOs), involving reimbursement rates, contract terms, problematic reimbursement guidelines, denials of coverage for necessary medical services, denials and underpayments of claims submissions, credentialing disputes, audit requests, gaps in the timely processing of claims, special investigative unit (SIU) investigations, recoupment/overpayment demands and other issues related to the payment and delivery of healthcare within a managed care network.

Members of our Payer Dispute and Managed Care Litigation Team understand the importance of maintaining strong relationships with payers while defending the interests of a wide range of healthcare clients and resolving reimbursement disputes efficiently and without disrupting provider-payer relationships. Many of our lawyers have prior experience representing both payers and providers, enabling us to better advocate for our provider clients as they navigate these often complex situations.

Our Experience and Capabilities

Contract Negotiations and Disputes. Beyond reimbursement rates, the provisions found within network agreements are prepared by astute lawyers on the payer side and can be incredibly impactful to every aspect of payer-provider interactions. Providers need sophisticated counsel to assist them in understanding and navigating these provisions. Our attorneys are well versed in identifying, resolving and – if necessary – litigating breach of contract claims against payers who violate terms of the network agreement.

Denial of Coverage/Medical Necessity. Providers may have specific legal remedies available in response to payer denials of coverage for medically necessary medical, behavioral and dental healthcare services. Our team has the knowledge and experience to guide providers in navigating all that is required to preserve the ability to seek recourse against improper denials of coverage. It is important that healthcare providers understand the requirements around exhaustion of administrative remedies and appeals, as well as dispute resolution procedures.

Underpayment of Claims. When providers are not reimbursed at a fair rate for services rendered, they may file lawsuits or incept arbitration proceedings alleging underpayment based on contract terms or prevailing market rates. Unfair reimbursement guidelines may also be an issue causing significant underpayment, or even denials, of legitimate claims. Our lawyers have extensive experience effectively addressing underpayment of claims.

Audits and Recoupment Demands. Providers often face both prepayment and post payment audits. These record requests can be both time-consuming and expensive efforts for healthcare providers. Our lawyers assist in navigating these requests and advancing appeals to any resulting claim denials or overpayment/recoupment demands.

Gaps in Claims Processing. Providers often encounter gaps in the payer's receipt and timely adjudication of claims as required under network agreement, prompt pay statutes or other applicable regulations. This can be the result of internal system issues or failures in a payer's ability to update credentialing, changes in location or other provider-specific information. These systemic issues can be incredibly frustrating and disruptive for providers. Our attorneys stand ready to assist.

Quality of Care Concerns. In some cases, providers may sue MCOs alleging that the plan's cost-cutting measures are compromising the quality of patient care, potentially leading to legal action based on patient harm. We assist clients in understanding and navigating these key provisions of the network agreement and work diligently to protect a provider's ability to deliver the best care to patients.

SIU Audits and Investigations. Our team has extensive and specific experience responding to SIU investigations and audits. Understanding the bases for these requests, statistical methods for any extrapolation utilized, and the nature of the audit and qualifications of the auditors is key to achieving an acceptable resolution for our healthcare provider clients.

Arbitration Clauses. Many managed care contracts include mandatory arbitration clauses, meaning disputes must be resolved through private arbitration instead of traditional court proceedings. Our team of healthcare litigators has extensive experience litigating arbitrations throughout the country.

No Surprises Act. We have substantial experience dealing with claims subject to the No Surprises Act (NSA). Our attorneys assist out-of-network healthcare providers subject to the NSA obtain payment, navigate the Independent Dispute Resolution (IDR) process and seek in-network status, where appropriate.

Bad Faith Claims. In some jurisdictions, providers may allege that the MCO acted in bad faith by denying coverage or underpaying claims without a legitimate basis. Our team helps clients navigate such matters as they arise.

Representative Payer Dispute Matters

• Assisted physician practices and other providers in negotiating in-network contracts with regional and national health insurers
• Assisted emergency ambulance transport clients in addressing claim denials and navigating the IDR process
• Assisted a large DSO in navigating and resolving extensive process gaps on the part of MCOs, resulting in the payment of hundreds of thousands of dollars in previously unpaid claims
• Assisted healthcare providers in dealing with and responding to health insurance audits and SIU matters
• Assisted a healthcare provider in appealing overpayment/recoupment determinations resulting from post-payment audits, resulting in the payer withdrawing millions of dollars in payment demands
• Assisted healthcare providers in responding to pre-payment audits and the resulting claim denials
• Assisted a healthcare provider in pended claims that were not timely adjudicated in violation of prompt pay statutes
• Assisted a healthcare provider in obtaining payments from defunct insurer, working with a state insurance commission and the payer
• Assisted a healthcare provider in advancing complaints to a state insurance commission to draw attention to improper claim handling practices, including pended and unadjudicated claims
• Assisted a home healthcare services provider with an internal audit regarding Medicare reporting compliance issues; identified, corrected and resolved the issues favorably for the client
• Resolved large volumes of denied and pended health insurance claims without litigation on behalf of a number of single-specialty and multispecialty physician practices and healthcare providers