Managed Care Disputes

Managed care is an essential part of today’s healthcare payment systems.  Especially as Medicare and Medicaid are increasingly delivered through the managed care model, it is essential to have counsel who are adept in navigating payment and who is familiar with both government and commercial healthcare regulation.

In approaching managed care disputes, Athene Law draws upon two advantages that set it apart for its peers. First, Athene Law attorneys regularly negotiate managed care agreements for a wide range of healthcare providers.  This gives them a broader perspective on how such agreements work in practice; how key contract terms are negotiated and operationalized; and how disputes arise and how they are resolved. Athene Law attorneys are also extraordinarily versed in the regulatory framework for both government and commercial payors.  Many attorneys claim to be familiar with California’s Knox-Keene Act.  Far fewer understand federal regulation of commercial health plans, including the Employment Retirement Income Security Act (ERISA), the Affordable Care Act (ACA) and the No Surprises Act (which applies to much more than surprise billing), or the complex or constantly-shifting underpinnings of the Medi-Cal or Medicare Advantage programs.

Athene Law handles managed care disputes for an unusually broad range of clients, including health systems, hospitals, independent practice associations (IPAs), medical groups, individual healthcare professionals, laboratories, and ground ambulance service providers.  We regularly advocate on behalf of such clients against payers, including Medicare, Medicaid, commercial health insurance plans, employer-sponsored self-insured plans, government programs, and accountable care organizations, to obtain fair payment.

Capabilities

Clients in the healthcare industry, including physicians and groups, facilities, for-profit and non-profit entities, hospitals, and hospital systems need guidance and representation for a variety of needs.

The following are representative of the range of healthcare disputes handled by Athene Law:

• Disputes over contract managed care negotiation and interpretation, including unbundling, stop loss, “Other Payor” provisions, narrow networks, coordination of benefits, DRG downcodes, the Two Midnights Rule, and credentialing issues
• Medical necessity disputes, including for trauma services
• Downcoding of evaulation & management (E&M) services in violation of the federal prudent layperson standard
• Suits for ERISA benefits, including to enforce federal mandates under the ACA, NSA, Mental Health Parity and Addiction Equity Act (MHPAEA)
• Out-of-network disputes under state law for the reasonable value of emergency services
• Challenges regarding outlier payments
• Financial assistance policy support
• Disputes with patients