Provider-Payor, Health Plan & Managed Care Disputes
ArentFox Schiff is a national leader in navigating reimbursement disputes for health care providers. Under the leadership of Caroline English, our team advises health care providers on managed care law, payor relationship issues, and reimbursement disputes. When litigation is necessary, we draw on our deep industry knowledge and litigation chops to help providers get the money they are owed.
What We Do
We represent health care providers in disputes with commercial payors, including some of the country’s largest health care insurance networks. We handle disputes ranging from a few hundred thousand dollars to hundreds of millions of dollars annually.
Our Focus
Our multidisciplinary team of over 20 professionals operates at the intersection of managed care, revenue cycle, and provider/payor relationships. We have decades of experience representing medical providers — whether as plaintiffs or defendants — in reimbursement disputes with commercial health plans and insurers, as well as government programs like Medicare Advantage and TRICARE.
We handle every stage of health benefits-related disputes, including contract negotiations, regulatory and compliance issues, administrative appeals, litigations, and negotiations, using our proprietary practice-specific case management system that allows us to manage and track large case volumes while providing exceptional client service and attention to detail. In court, we pursue claims by providers both directly (e.g., contract, common law) and as ERISA assignee-based claims. We have a national practice, litigating in forums all over the country, including state and federal court and in arbitration.
Our Experience
Our substantive experience with health insurance and benefits plans and managed care laws includes:
- ERISA, including ERISA preemption issues
- ACA
- COBRA
- FEHB
- HIPAA
- TRICARE
- State insurance laws, prompt pay laws, and pricing transparency laws
- Medicare Advantage
- Medicare Secondary Payer Act
- No Surprises Act
- Bankruptcy laws pertaining to retiree health benefits
Our Clients
- Dialysis providers
- Hospitals
- Clinical laboratories
- Pharmacies
- Ambulatory surgery centers
- Anesthesia providers
- Physician practices
- Medical device companies
- Urgent care centers
- Ambulance providers
- Specialty health providers
- Accountable care organizations
Our Work
Reimbursement & Coverage Disputes
- Out-of-network reimbursement disputes
- Coverage disputes
- “Usual, customary, and reasonable” or “UCR” calculations
- Recoupment and overpayment demands
- Payor audits and investigations
Contracting, Network Status & Provider Relationship Disputes
- Commercial payor breaches of managed care contracts, preferred provider arrangements, third-party network contracts, and single case/single patient treatment agreements
- Repricer interference
- Benefit carve-out and design challenges to in-network status and payments
- Terminations of provider agreements
ERISA Appeals and Litigation
- ERISA administrative claims and appeals challenging adverse benefit determinations
- Derivative and fiduciary breach claims on behalf of providers standing in their patients’ shoes
- Plan fiduciaries’ failure to follow proper claims and appeals procedures or plan violations
- Disputes requiring negotiations with plan sponsors over unlawful plan terms
- Litigating ERISA preemption defenses
Government Benefit Program Claims and Disputes
- OPM and FOIA claims with respect to FEHB Plan disputes
- FEHB, TRICARE, and state government program payment determination disputes
- Medicare Parts A and B eligibility, enrollment, and entitlement issues, including retroactive entitlement determinations
- Medicare Advantage plan claims and appeals; rights under Medicare Advantage regulations
- Alleged overpayments associated with Medicare, Medicaid, and other government payers
ACA-Related Advisory Work & Litigation
- Advising on ACA health plan exchanges, including eligibility and enrollment; plan options and benefits; rights and obligations under the ACA; intersection of ACA requirements with other federal and state law requirements; and litigating ACA violations
Coordination of Benefits, MSP Act & Related Litigation
- Violations of the Medicare Secondary Payer (MSP) Act, including MSP Act discrimination claims
- Coordination of benefit disputes
Audit, Recoupment & Overpayment Challenges
- Payor audits and investigations
- Challenging audit findings, overpayment demands, and recoupment actions issued by third-party administrators, pharmacy benefit managers (PBMs), insurers, and health plans
Documentation, Intake Process & Best Practices Counseling
- Advising providers on best practices for intake procedures
- Advising providers on best practices for collection and revenue cycle management
- Drafting insurance verification, intake, and assignment of benefits documentation
Value Based Care
- Disputes between ACOs and health insurers arising under value based care agreements
