The New Playing Field for California Non-Par Provider/Payor Litigation

Two recent cases published in California are changing the landscape for litigation between non-contracted providers and health care payors. The first case, Children’s Hospital Central California v. Blue Cross of California, 226 Cal.App.4th 1260, 172 Cal.Rptr.3d 861 (Cal.App. 5 Dist., 2014) found that the six- part test in H&S Code Section 1300.71(a)- (3)(B), describing the … Continue Reading »

Managing Overpayments: A Change in Landscape

Health plans seeking overpayment recovery from network providers may need to evaluate the member’s plan with consideration to ERISA notice and appeal rights.

Recent rulings have made what was once relatively routine for health plans more challenging. Prior to these rulings, the provider claims adjudication process contemplated ongoing adjustments for underpayment and overpayment of claims, and in many cases handled cases through a notice or joint plan–provider meetings. Provider contracts typically grant the payor setoff and recoupment rights … Continue Reading »

Arbitration of Medicare Coverage Disputes: An End-Around Preemption?

It is fairly common for a contract between a health care provider and a private insurance plan to include an arbitration provision governing disputes that arise under their contract. As a result, disputes between payors and their contracted providers—for example, overpayment and underpayment disputes—are often resolved through private arbitration, rather than the court system. But … Continue Reading »

“Is That Protected?”

Protective orders are on the rise as insurers have become increasingly reluctant to produce documents, including an insured’s claim and underwriting files, for fear of exposing confidential and proprietary information to competitors. Successfully protecting these documents is dependent on the issues in the case and how narrowly tailored the protective order is. Under Rule 26(c), … Continue Reading »

Hospice Care and the Shifting Focus of False Claims Act Enforcement

With an increasingly large population of elder individuals, the demand for hospice services over the past decade has seen a dramatic rise. In fact, between 2003 and 2011, the amount of funding being expended on hospice services nationwide has more than doubled—increasing from $5.9 billion to nearly $14 billion annually. Unfortunately, with the increased demand … Continue Reading »

Indian Health Service Recovery Efforts Against Commercial Health Plans

Health plans across the country are increasingly receiving demands for payment from the Indian Health Service, tribal health programs (“Indian Organizations”) and the U.S. Department of the Treasury for services provided by Indian Organizations to a health plan’s members. These claims for recovery are premised on the fact that Indian Organizations are generally considered a … Continue Reading »