Managed Care

Dispute Resolution

Hooper, Lundy & Bookman is the preeminent law firm representing providers in disputes with health plans, insurers, preferred provider organizations and other managed care organizations. Through litigation, arbitration, mediation and negotiation, we have recovered well over one hundred million dollars for our managed care provider clients in a variety of payment disputes.

We represent clients in a variety of situations in which payors have used different reasons for non-payment or underpayment of claims. The issues involved include problems such as:

• Contract interpretations
• Omitted terms in contracts
• Contract terminations
• Incorrectly loaded rates
• Late billings
• Late payments
• Overlapping and complex regulatory requirements
• Multiple payors responsible for the same services
• Payors merging with one another
• Improper deductions and recoveries
• Improper reimbursement standards
• And many other issues

Our attorneys represent many providers in non-contracted disputes, which involve questions regarding the usual and customary rates which the providers are entitled to receive. In addition, we have extensive expertise in ERISA litigation, as many self-funded payors attempt to deny or to limit payments by asserting ERISA preemption. We also represent a variety of different providers in Workers Compensation disputes.

The firm has also assisted our provider clients in defending cases filed against them by payors. Many times payors seek to recoup or offset alleged overpayments. We have found that repayment demands often can be successfully challenged through applicable legal defenses, with the result being that the provider owes little or nothing at all under the applicable contract or law. Payors also sometimes pursue legal recourse for early termination, whether caused by disputed grounds for breach, change of ownership, or otherwise. Once again, we have found that providers often have good defenses to these types of claims.

Another equally important part of our managed care practice involves handling multi-party disputes. Unlike most business areas, managed care disputes often involve more than two sides, a growing trend as more health plans open their networks to other payors, and delegate responsibilities to other entities. Our firm specializes in understanding, addressing and resolving the types of problems created by these unique challenges to the managed care field.

Regulatory Expertise

One of the hallmarks of our managed care practice is our thorough understanding of applicable federal and state laws and regulations, including California’s Knox-Keene Act and Insurance Code, as well as the inner workings of state and federal agencies that regulate managed health care. Because of our ability to work within this complex regulatory structure, we maintain excellent relations with managed care regulators. As a result, we are successful in moving our clients’ matters expeditiously through the regulatory process.

Contracting and Transactions

The firm regularly represents hospitals and other providers in structuring and negotiating their relationships with health plans, preferred provider organizations and other third-party payors. Negotiations involve both capitation and fee-for-service contracts, as well as risk sharing and co-management arrangements for coordinating hospital and physician incentives in a managed care environment. Hooper, Lundy & Bookman has reviewed numerous HMO, PPO, senior, commercial, transplant, and third party payors contracts involving almost every health plan and insurer.

We believe the depth of our managed care experience and expertise exceeds that of any other law firm in California in assisting clients in meeting the Department of Managed Health Care’s (DMHC’s) requirements for Knox-Keene licensure. We draw upon our experience of dealing with dozens of Knox-Keene organizations, including specialty vision and other specialized plans, our experience with DMHC and other government agencies, and our decades of experience representing the provider community. We have the resources to effectively handle a Knox-Keene licensing project from the earliest planning stage to the filing of the application for licensure, to the response to all regulatory concerns, and final achievement of the license.  Our knowledge of the industry is unsurpassed, and our ability to anticipate and often quell concerns before they become problems is a hallmark of the firm.

Our attorneys have assisted more than 20 companies obtain Knox-Keene licenses and have worked with dozens of licensees on achieving Material Modifications to existing licenses.

Some examples our recent successes with DMHC on behalf of clients include:

• Assisting a large medical group in obtaining a full service provider-based Knox-Keene license
• Working with specialized health plans on post-licensure regulatory issues
• Representing a multi-hospital integrated delivery system in all aspects of the acquisition of assets of a Knox Keene plan and the related application for a new Knox-Keene license for the system’s health plan, which we also helped to secure for the client
• Assisting several health care providers in pursuing regulatory actions with the cooperation of DMHC

Client Advocacy

Our clients span the full spectrum of institutional, professional and ancillary providers within the managed care industry. We represent providers of all sizes, from some of the largest healthcare systems in the country, to mid-sized companies, stand alone businesses, and successful individual practitioners. Because managed care is constantly evolving, we are also involved in influencing industry changes on our clients’ behalf through our active participation in trade associations, legislative drafting and other forums for promoting legislative and regulatory change. We have deep roots in the managed care business and have grown up right along with it.