Health Care and FDA: Health Care Payor-Provider Disputes (U.S.)

Our payment dispute experience includes, but is not limited to, the following categories:

• Disputes against various commercial insurance payors, including:
  • State court and federal court lawsuits over contract term interpretations.
  • ERISA and non-ERISA claims.
• Disputes against various managed care organizations, including:
  • Conventional managed care contracting disputes, including right of payment and rate of payment disputes.
  • Disputes with Medicare Advantage Organizations over Medicare Advantage  contract interpretation issues.
  • Suits under various state laws requiring specific reimbursement levels for certain types of services.
  • Suits challenging whether purported Preferred Provider Organizations (PPOs) satisfy state statutory PPO definitions.
• Out-of-network provider versus payor disputes, including issues such as:
  • Copayment and other cost-sharing waivers.
  • ERISA and non-ERISA claims.
  • Usual, customary, and reasonable charges.
  • Whether a treatment is experimental or investigational.
• Disputes against state Medicaid agencies, including:
  • Agency recoupment efforts.
  • Agency payment denials.
  • Cost report challenges.
  • Enrollment disputes.
• Appeals of Medicare and state Medicaid audits.
• False Claims Act disputes.
• Medicare disputes before the Departmental Appeals Board, Medicare Administrative Contractors, the Medicare Appeals Council, and Federal Administrative Law Judges.