Managed Care Litigation
The lawyers in Clark Hill PLC’s Managed Care Litigation Group have developed a deep understanding of health insurance and managed care issues in the approximately forty years that we have attended to the litigation needs of businesses in those industries. Our attorneys have litigated disputes in federal and state trial and appellate courts, bankruptcy courts, and administrative agencies throughout Pennsylvania and the country against individuals, companies, institutions, trade associations and putative classes.
Clark Hill’s lawyers have represented both for-profit and not-for-profit health insurers and managed care businesses in their disputes with enrollees, with each other and with providers – both professional and institutional, and both out-of- and in-network.
Coverage Litigation – Clark Hill lawyers have advised on and litigated disputes with enrollees about payment for preexisting conditions, diagnostic admissions and purely elective procedures. We have defeated claims for coverage under both ERISA and non-ERISA plans.
Disputes with Professional Providers – Clark Hill’s attorneys have extensive experience with allegations that our clients have improperly calculated usual, customary and reasonable (UCR) rates. We have assisted our clients in seeking recovery when providers have engaged in fraud, in terminating in-network providers who have persisted in overprovision of medical services and in defending challenges to retrospective audits and utilization reviews, including class action challenges.
Disputes with Institutional Providers – We have represented our clients in disputes with hospitals, emergency service providers, home health providers and nursing homes. These disputes have involved both the appropriate amounts of payments to these providers and how those payments are calculated, accounted for and made.
Antitrust Claims – Clark Hill attorneys have represented managed care and other clients in antitrust cases for many years. We have successfully pursued group boycott claims against providers and defended our managed-care clients against those claims. We have also defended our clients against claims of price fixing.
Proceedings in Bankruptcy Court – We have represented health insurers and managed care businesses in advancing claims against bankrupt providers, in avoiding improper assumptions and assignments of contracts and in defending against claims by bankrupt entities.
Obtained dismissal in federal court of putative class action by non-participating EMS providers and trade association seeking to force our client to pay claims directly to them and alleging violation of RICO statute.Defeated claims of providers alleging that they were improperly selected for post-payment review.Obtained favorable settlement of class action by pharmacists alleging breach of pharmacy service agreements.Negotiated consent agreement requiring state dental association and individual providers to end group boycott of participation in client’s insurance plans.Defeated claims in bankruptcy court that client’s refusal to continue dealings with customer in arrears had improperly caused customer’s insolvency.Represented third-party administrator in protracted action that was favorably resolved after one-day mini-trial of ERISA breach of fiduciary duty claims.Obtained appellate reversal of trial court’s refusal to require two health insurers to arbitrate dispute as provided by contract.Assisted managed care company in recovering overpayment to providers who had up-coded services and improperly fragmented services into multiple codes.
Assisted clients on how to respond to growing demands to make their companies and products more sustainable, a goal increasingly being adopted by companies in the health care industry
Commented on EPA rulemaking s for a trade association representing a segment of in the health care industry
Tracks regulatory developments for health care industry clients to provide early warning of significant new regulations or risks to a company's business, particularly concerning issues relating to FIFRA compliance for chemicals which claim to reduce Ebola, norovirus, and other viruses that are unlikely to have been explicitly testing in the original pesticide registration process
Advised on methods of responding to regulatory agency and press concerns about the presence of "toxic" chemicals in products used by the health care industry
With assistance from Kristi Gauthier, Ed Hammond, Peter Domas and Bishop Bartoni, Kevin Hendrick and Nicole Tersigni successfully defended an insurance priority dispute, resulting in an extremely favorable judgment for firm client, United States Steel Corporation’s ERISA-governed Retiree Benefits Plan. U. S. Steel Retirement Plan was joined as a third-party defendant in a pending dispute by a No-Fault Automobile Insurance carrier, which had been sued by a healthcare service provider for unpaid patient attendant care fees. The No-Fault Carrier claimed that the obligation to pay for these services under Michigan No-Fault law fell to U. S. Steel Retirement Plan, which covered the patient (who was a former U. S. Steel employee). Ed, Bishop, Kristi and Peter lent their expertise to Kevin and Nicole in interpreting alleged conflicting insurance priority provisions and explanations of benefits. Kevin and Nicole crafted a legal argument that ultimately led to summary disposition in favor of U.S. Steel Plan, and against the No-Fault carrier, saving U.S. Steel Plan from payment of the healthcare fees, and also reimbursing U.S. Steel Plan for benefits it had earlier paid by mistake, out of priority. As the No-Fault carrier had rejected the Case Evaluation award prior to the filing of cross motions for summary disposition, it also appears that attorney fees are recoverable for our client. Kristi and Ed on Employee Benefit law, Bishop on Michigan No-Fault law, and Pete on Health Care issues, proved to be unbeatable resources.
Managed Care and Health Care Industry Litigation - Practiced before state and federal agencies and the courts relating to Medicare and Medicaid reimbursement issues.
Health Care Industry Litigation - Participated and litigated in several federal bankruptcy and state court receivership proceedings of hospitals.
Antitrust and Trade Regulation - Lead Counsel in an antitrust case which successfully put an end to a decade’s long boycott against one of the largest dental insurers in the country.
Managed Care and Health Care Industry Litigation - Counseled clients and litigated third party reimbursement and accounting for reimbursement issues.
Antitrust and Trade Regulation - Reported antitrust decisions include the following: Pennsylvania Dental Association v. Medical Service Association of Pennsylvania, 815 F.2d 270 (3d Cir. 1987), rev’g, 632 F.Supp. 653 (M.D. Pa. 1986), cert denied, 484 U.S. 851 (1987); Pennsylvania Dental Association v. Medical Service Association of Pennsylvania, 745 F.2d 248 (3d Cir. 1984), aff’g, 574 F.Supp. 457 (M.D. Pa. 1983), cert. denied, 471 U.S. 1060 (1985).
Antitrust and Trade Regulation - Antitrust litigation experience includes representing clients in the insurance, health care, soft drink, construction, manufacturing, hardware and building materials industries.
Managed Care and Health Care Industry Litigation - Litigated provider participation status under the Medicare program.
Managed Care and Health Care Industry Litigation - Litigated issues related to institutional providers’ Medicaid cost reports.
Counsel to mid-market health care companies including cancer treatment centers, dialysis centers, sleep labs, and ambulatory surgery centers providing lead counsel and coordinating legal counsel on a wide array of matters including corporate matters, operations, acquisition and divestiture transactions, joint venture projects, corporate governance, business planning and financial transactions, and legal compliance.
Represent healthcare insurers, third party administrators, managed care organizations and others in contractual, business and other disputes. Representation includes counseling clients and litigating issues regarding payments, accounting for payments, third party administration and self-insured health plan issues, fraud claims, among others