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Health Care Payor-Provider Disputes (U.S.)

K&L Gates has a significant number of lawyers in numerous jurisdictions who are experienced in representing health care providers in all types of payor disputes.

Our representative clients run the spectrum and include providers such as hospital systems (including AMCs), ambulatory surgery centers, behavioral health providers, freestanding diagnostic and treatment facilities, nursing facilities, adult care facilities, continuing care retirement facilities, home health and hospice agencies, dialysis providers, clinical laboratories, and physician groups.

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 (“MAO”) over Medicare Advantage (“MA”) contract interpretation issues 
    • Suits under various state laws requiring specific reimbursement levels for certain types of services 
    • Suits challenging whether purported 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 CMS 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 (“ALJs”)
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Partner
P +1.973.848.4104
Partner
P +1.949.623.3526
Of Counsel
P +1.717.231.5817
Partner
P +1.206.370.8317
Associate
P +1.919.314.5624
Partner
P +1.919.466.1195
Associate
P +1.973.848.4028
Managing Partner, Newark Office
P +1.973.848.4014
Senior Of Counsel
P +1.412.355.6484
Partner
P +1.206.370.7613
Partner
P +1.312.781.6010
Associate
P +1.919.466.1188
Partner
P +1.919.466.1182
Partner
P +1.214.939.6235
Partner
P +1.206.370.8070
Practice Area Leader - Litigation
P +1.412.355.8385
Partner
P +1.843.579.5638
Partner
P +1.214.939.5659
Managing Partner, Miami Office
P +1.305.539.3353
Showing 1-10 of 23 results
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Represented a hospital in Administrative Law Judge review of 460 CMS reconsideration decisions within CMS’s Office of Medicare Hearings and Appeals (“OMHA”). The reconsideration decisions denied pre- and post-payment Medicare reimbursement claims and CMS recouped approximately $7.6 million from the provider. Prior to the ALJ Hearing, K&L Gates, along with the provider, participated in OMHA’s Settlement Conference Facilitation Program and settled the 460 Medicare claims.
Represented plaintiff providers against a Medicare Advantage Organization alleging that the MAO owed Plaintiffs for underpayments (since 2013). The MAO applied a two percent (2%) sequestration reduction in reimbursement to covered services paid to Plaintiffs for services provided to Medicare Advantage members without authority and in violation of the contracts between Plaintiffs and the MAO.
Represented a provider in an arbitration alleging that a Medicare Advantage Organization improperly paid the provider, an out-of-network provider, a rate below the Medicare rate. As an out-of-network provider, the MAO was obligated to pay the provider at least the Medicare rate for its Medicare Advantage patients. Because the MAO was found to have committed unfair and deceptive trade practices, the provider was awarded treble damages. The MAO was ordered to pay the provider treble the remaining amount owed as required by law and interest. The case was later settled.
Successfully prosecuted claims for Robert Wood Johnson University Hospital (“RWJ”) against Horizon, New Jersey’s largest health insurance company. Key to success was securing a reversal at the Appellate Division of the trial court’s ruling that the Health Services Corporations Act precluded recovery of full out-of-network rates for services provided to non-HMO Horizon subscribers. In doing so, the Appellate division rejected the New Jersey Commissioner of Insurance’s interpretation of the relevant statute. We leveraged this success into a favorable outcome whereby RWJ recovered out-of-network rates and ultimately entered into a favorable in-network contract.
Represented a large health care system serving 24 counties in north Mississippi and northwest Alabama in its dispute with UnitedHealthcare. Our client provided UnitedHealthcare with notice of their intent to terminate their in-network contract due to underpayment of claims and several other operational issues. UnitedHealthcare filed for arbitration based on wrongful termination of the contract and our client counterclaimed. Termination of the contract would have rendered our client an out-of-network provider which would have affected over 730,000 people. We formulated the public relations and operational strategies for our client, which involved sensitive tactics to maintain healthy relations with the local community and aided in the successful negotiation with UnitedHealthcare whereby a renewed contract for a three-year term was reached.
Successfully prosecuted counterclaims while defending Bayonne Medical Center (“BMC”) against insurance fraud claims brought by Horizon, New Jersey’s largest health insurance company. After years of discovery, we won summary judgment dismissing all of Horizon’s claims, which centered upon alleged “fee forgiveness” (Horizon alleged BMC waived co-pays and patient cost share to entice Horizon patients to go out-of-network). After securing insurance coverage to defend Horizon’s claims, we also sustained counterclaims against the insurer for substantial underpayments (out-of-network charges for medical services) on summary judgment. We leveraged these successes into a favorable settlement, collecting significant reimbursements and gaining an in-network contract for BMC and affiliated hospitals.
Successfully prosecuted counterclaims while defending BMC against a similar suit filed by Aetna. Aetna similarly claimed that waivers of patient responsibility violated the Insurance Fraud Prevention Act and constituted common law fraud, negligent misrepresentation, and tortious interference and encouraged overutilization of services at a more expensive out-of-network facility. We won summary judgment in BMC’s favor, dismissing with prejudice Aetna’s claims for insurance fraud, common law fraud, negligent misrepresentation, and tortious interference. We also sustained BMC’s counterclaims against Aetna for its substantial under-reimbursements to the hospital for medical services provided to its subscribers in violation of applicable law and Aetna’s own insurance plans.
Currently prosecuting a claim on behalf of Hoboken University Medical Center against three separate defendants — an ERISA plan, the plan administrator (Omni Administrators, Inc.), and the third-party claims administrator (Aetna Health Inc.). The suit alleges that the plan substantially underpaid the hospital for extensive emergency treatment provided to one of the plan’s members and that the other defendants violated their fiduciary duties under ERISA and failed to provide the hospital adequate review procedures. To date, we have successfully defeated three separate motions to dismiss: (i) one by Aetna, the third-party claims administrator, alleging that it could not be liable for a fiduciary breach; (ii) one by Omni, the plan administrator, alleging that it could not be liable for a fiduciary breach or failure to provide a full and fair review; and (iii) one by all three defendants, challenging the validity of the assignment of benefits in the hospital’s favor. The case remains ongoing.
Initiated and settled case on behalf of out-of-network medical device company against insurer for wrongfully denying and underpaying covered claims; assisted in negotiation of in-network contract.
Successfully defeated the insurer’s motion to dismiss our client's denial of benefits claims under ERISA, convincing the court that our client had sufficiently alleged that it had standing to sue the insurer under ERISA in an action on behalf of a manufacturer of a colorectal screening test.