Managed Care and Health Care Law

Our goal is to provide our clients in the healthcare field with benefit, value and results. We represent and advise our clients in a wide array of areas, such as:

  • Provider Agreements- We will assist you in negotiation of provider agreements with insurers/payors so that you can obtain the best rates of reimbursement available. As important is securing contractual protections and processing methodologies that support your practice. Our significant business and litigation experience in managed care and health law guide our counsel and provides real value in spotting and remediating potential controversies and issues in the contract before they occur.
  • Provider Reimbursement & Payment- We assist in the collection of funds due to providers through various means. When necessary, we commence and prosecute lawsuits (as well as arbitrations and mediations when it is required or appropriate) to recover money you have earned and are due as a result of underpayment by payors/insurance companies. We have successfully litigated the following issues, and more:
    • Participating provider litigation, such as failure to honor provider agreements, coding or other industry standards, or pre-certification
    • Non-participating or out-of-network provider litigation, a resolution of which may be negotiating and executing beneficial provider agreements
    • Denials based on claims of lack of medical necessity or lack of coverage
    • Untimely processing of claims and appeals, including prompt pay law violations
    • Improper processing and/or pricing of claims
    • Downcoding and Bundling
    • Improper Coding or otherwise not following accepted coding guidelines
    • Independent Dispute Resolution (IDR)
  • Claim and Processing Analysis- We have reviewed claims with providers to provide counsel for the following issues:
    • Inconsistent applications of claim payment policies, practices, and payments by payors in contravention of provider agreements, coding standards, or other industry standards, including payment variations for comparable procedure codes for similar services as well as inconsistent application of claim adjudication rules.
    • Out-of-network claims. We counsel providers with respect to properly submitting claims to out-of-network payors, including receiving proper assignment of benefits and fully appealing or utilizing the administrative process of payors (and properly documenting these efforts). We also review the payments of out-of-network payors to ensure that providers receive the full amount of the out-of-network insurance benefit owed to them by comparing Usual, Customary and Reasonable (UCR) Rates, FAIR Health, and other factors.
    • Inconsistencies in billing submittals and coding practices of clients, which can be counter-productive to the receipt of full payments.
  • Fraud Investigation and Defense, including Defamation by Payors- We have defended providers in allegations of fraud from state agencies or insurance special investigation units. In addition to defending providers in these areas, we have prosecuted defamation claims against insurers for false allegations of fraud.
  • Audits- We have represented providers in claim audits commenced by state agencies and payors.
  • Take Backs and Offsets- We have sought recovery of a payor’s unilateral take back or offset of payments through litigation and pre-litigation intervention.
  • Patient Privacy and Security Law- We have counseled clients on HIPAA compliance and data security so as to ensure you avoid potential pitfalls and fines.
  • Business Transactions & Organizations- We will assist you in negotiation and preparation of contracts with respect to mergers with other groups or providers so that you can get the best return on your investments.
  • Employment issues- We can assist you with a wide array of employment related headaches and minimize risks of lawsuits by providing you guidance and expertise in drafting and negotiating employment contracts, license and privilege issues, or other areas such as complaints of discrimination and harassment.
  • Stark and Anti-Kickback- We can help you navigate through issues that arise when doctors groups enter into relationships with other health care groups so as to minimize costs.