Payor-Provider Disputes


Providers regularly face frustrating and daunting reimbursement challenges with commercial payors. Both substantial sums and a host of substantive issues are involved in payor-provider disputes. Hooper, Lundy & Bookman has successfully resolved countless complex payment disputes, securing hundreds of millions of dollars for providers of all kinds through strategic advocacy and comprehensive knowledge of the legal landscape governing payment and reimbursement issues.

Our exclusive focus on health care law is the foundation upon which HLB has built a nationally recognized practice designed to get providers every dollar to which they are entitled from private payors. Clients across the patient care spectrum turn to us to parry efforts by payors to challenge or deny payment and reimbursement obligations. We represent hospitals and hospital systems, physicians and physician groups, clinical laboratories, long-term care providers, skilled nursing facilities, hospices, behavioral health providers, clinically integrated networks, suppliers, pharmacies, academic medical centers, drug and medical device companies, and health care technology companies in payment disputes of all kinds.

A Collaborative Team to Successfully Resolve All Payment Disputes

A collaborative team of litigators, regulatory and compliance attorneys, and lawyers with immersive experience with billing, coding, coverage, and payment issues come together to provide comprehensive representation in the full range of payor-provider payment disputes, including those involving:

  • State court litigation, federal court litigation, and arbitration dedicated to contractual interpretation and/or breach disputes
  • Issues involving ERISA based claims for self-funded plans
  • Out-of-network provider versus payor disputes
  • Copayment and other cost-sharing waivers
  • Disputes against state Medicaid agencies, including:
    • Agency recoupment efforts
    • Agency payment denials
    • Cost report challenges
    • Enrollment disputes
  • Appeals of Medicare and state Medicaid audits
  • Medicare disputes before the Departmental Appeals Board, Medicare Administrative Contractors, the Medicare Appeals Council, and Federal Administrative Law Judges
  • Payor audits, recoupment attempts, and investigations, including pre-payment review and Special Investigations Unit (SIU) related issues
  • Federal preemption issues
  • Coverage disputes
  • Coordination of benefits issues
  • Dealing with credit balances and overpayments
  • Network and preferred provider disputes
  • Letter of Agreement (“LOA”) breaches
  • “Usual, customary, and reasonable” disputes
  • Review and negotiation assistance with payor-provider contracts

Consistent Success in Managed Care Payment Disputes

Hooper, Lundy & Bookman is particularly well-known for its acumen and success in representing providers in disputes with health plans, preferred provider organizations, insurers, and other managed care organizations. Through litigation, arbitration, mediation, and negotiation, we have recovered well over $100 million for our managed care provider clients in a wide range of payment disputes.

We represent clients in a variety of situations in which payors have asserted different reasons for non-payment or improper underpayment of claims, including:

  • Contract interpretations
  • Omitted terms in contracts
  • Contract terminations
  • Incorrectly loaded rates
  • Untimely submission of claims and/or appeals
  • Lack of authorization or pre-approval for services
  • Medical necessity and/or experimental or investigational denials
  • DRG-related issues 
  • Capitation-related issues
  • Overlapping and complex regulatory requirements
  • Multiple payors responsible for the same services/coordination of benefits
  • Payors merging and/or termination of contract with Third-Party Administrator (“TPA”)
  • Improper deductions and recoveries
  • Improper reimbursement standards