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Managed Care Litigation

The attorneys in Clark Hill’s Managed Care Litigation group have developed a deep understanding of health insurance and managed care issues in the approximately 40 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 the country against individuals, companies, institutions, trade associations, and putative classes.

Our attorneys 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

Our attorneys 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 the Employee Retirement Income Security Act of 1974 (ERISA) and non-ERISA plans.

Disputes with Professional Providers

Our 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 by 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

Our 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.

Representative Matters

  • Obtained dismissal in federal court of a 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 the client’s refusal to continue dealings with a customer in arrears had improperly caused customer’s insolvency
  • Represented third-party administrator in protracted action that was favorably resolved after a one-day mini-trial of ERISA breach of fiduciary duty claims
  • Obtained appellate reversal of a trial court’s refusal to require two health insurers to arbitrate a dispute as provided by contract
  • Assisted a managed care company in recovering overpayment to providers who had up-coded services and improperly fragmented services into multiple codes.