Managed Care
Since 1984, the Firm has concentrated in defending all types of managed care organizations in virtually every type of claim that can be brought either by providers or subscribers. The Firm has also been providing Risk Management advice and counseling to its clients since its inception. The Firm's managed care practice includes:
Denial of Benefits
Our attorneys defend denial of benefit claims brought by members of a managed care organization, including claims defended on the basis that the services were not medically necessary, were experimental or investigational or because the service was excluded in the Plan documents or not a covered benefit. Where appropriate, the Firm routinely removes these cases to Federal Court on the basis of ERISA preemption. Many of the Firm's attorneys participate in member grievances at the Plan level, advise the Plan appeal panels and attend appeal hearings where appropriate. The Firm also frequently represents its clients before the Center for Health Dispute Resolution, and at various state and federal agency forums across the country. The Firm has extensive experience in defending claims based on rescission of a subscriber contract and provides advice to clients on the proper policies and procedures to maintain an effective and risk free Rescission Department. 
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Provider Disputes
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Our attorneys defend managed care organizations in disputes with providers, including individual provider payment disputes, as well as class actions, physician grievances, fraud and abuse, contract termination, unlawful retaliation claims, fair hearing requirements, exclusivity provisions, and claims of anti-trust violations. We also handle cases involving prompt pay issues, claims involving disputes over the usual, customary and reasonable charge to be paid to a provider, issues concerning the professional component of clinical pathology, physician ranking, and virtually all types of contractual and statutory based disputes. The Firm defends these cases in state and federal court, as well as before state agencies and at state and federal administrative hearings both in Florida and nationwide. We have participated in virtually every type of Alternative Dispute Resolution process that is utilized to decide these issues.
The Firm defends provider related claims brought through arbitration. Since many provider contracts require arbitration, the Firm defends cases brought under the Commercial Rules of Arbitration, Federal Arbitration Act and specific state law arbitration rules. These cases involve claims that are arbitrated pursuant to private arbitration rules set forth in a contract, the rules of the American Arbitration Association, the American Health Lawyers Association Rules for Arbitration, JAMS and other arbitration association rules.
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Medical Malpractice
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The Firm defends managed care organizations in claims based on medical malpractice including claims of direct liability and vicarious liability. The claims of direct liability are based on theories that include negligent selection, credentialing and retention of contracted providers, negligent denial of medically necessary care and treatment, corporate negligence and joint enterprise. Vicarious liability includes claims based on the medical care rendered by both employed and contracted providers.
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Vicarious Liability
In 2003, the Firm drafted legislation designed to provide immunity for managed care organizations for claims of vicarious liability based on the treatment rendered by independent contracted providers. This legislation was passed in September 2003 and has greatly reduced the number of claims based on vicarious liability being filed in Florida. In the event a managed care organization does not fall within the purview of the Reform Law, the Firm defends these cases on the basis that the managed care organization is not liable for the acts of providers with whom it contracts. The Firm also defends these cases in other parts of the country where HMO reform does not exist.
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Negligent Credentialing and Retention
The Firm defends cases brought by subscribers alleging that the managed care organization failed to properly credential a provider who committed medical malpractice and the managed care organization is therefore responsible for injuries suffered by the subscriber/patient. The Firm defends these claims by utilizing the applicable state and federal peer review privileges that exist as well as defending on grounds such as there is no proximate cause between the credentialing allegations and the injuries. In addition to defending these claims in litigation, the Firm drafts policies and procedures for credentialing committees to use to avoid liability, and Firm attorneys provide legal counsel on the way to conduct peer review proceedings.
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Utilization Management
The Firm defends managed care organizations in claims brought by subscribers alleging that the denial of requested medical care and treatment caused injury to the subscriber. These claims are brought for breach of contract under state and federal law seeking payment for the cost of the medical treatment as well as claims for physical and emotional pain and suffering if the subscriber failed to get the requested treatment and suffered an injury.
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Managed Care Operational Issues
In addition to defending managed care organizations in litigation, the Firm regularly provides counsel to its clients on operational issues that our clients face in promoting, maintaining and growing their business. The Firm assists clients with these needs by drafting provider and subscriber agreements, developing credentialing policies and procedures, participating in the grievance and appeal process, participating in peer review committees, designing policies and procedures related to claims handling and subrogation issues, formulating utilization and quality management protocol, drafting marketing materials, and designing fee schedules.
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Risk Management Services
The Firm provides Risk Management services to its clients on a nationwide basis. The services include providing advice and counsel to clients as they make real time business decisions involving issues with subscribers, providers, customers and vendors. As to subscribers, the Firm advises in-house legal departments, medical directors and complex case managers on benefit determinations including review of plan language, drafting of letters to providers and subscribers and providing guidance on the plan's handling of requested medical care. As to providers, the Firm provides counsel on provider disputes in an effort to avoid litigation including reviewing the contracts in dispute and providing strategy, advising on the status of non-participating fee methodologies, interpreting and advising on statutory reimbursement issues, providing direction on methodology related to credentialing and peer review issues.
The Firm also reviews provider contract and subscriber contracts, policies and procedures for the various departments in a managed care organization, websites, marketing materials, enrollment information, and grievance and appeal processes and advises clients on areas of potential liability and provides suggested language changes to avoid liability.
The Firm also conducts seminars for its clients with the goal of advising clients of the legal issues that face managed care organizations. In these seminars, the Firm provides advice for identifying problems as they arise and provides specific mechanisms to try to resolve issues before they became lawsuits. These seminars are presented to in-house legal departments, senior finance staff, medical directors, case managers and nurse reviewers, marketing departments, customer service representatives, provider relations personnel, claim departments and provider operations staff.
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