Managed Care + Employee Benefit Litigation

Overview

Managed care organizations and health insurers face unique regulatory, legal, and economic challenges. Navigating the evolving landscape of state and federal health benefits law requires far-reaching experience and a real understanding of the managed care and health insurance business. Robinson+Cole lawyers have both.

Our Services

We regularly represent managed care and health insurance clients in a wide range of matters, including the following:
•  administrative hearings before state and federal regulators
•  disputes under prompt pay statutes
•  Medicaid-managed care
•  Medicare Part D
•  market conduct litigation
•  ERISA compliance and health claim litigation
•  out-of-network provider reimbursement
•  utilization review requirements
•  state licensure
•  antitrust government investigations

Our Team

Effective Case Management

We have represented managed care and health insurance clients for more than two decades as outside general counsel in litigation, corporate, and regulatory matters that include the following: 
•  national managed care organizations operating public and private sector health plans
•  insurers in the individual and small group markets
•  pharmacy benefit managers
•  excess loss carriers
•  third-party administrators
•  self-funded employer groups
In addition, we have served as general counsel to the Connecticut Life and Health Insurance Guaranty Association for over 10 years.
Our lawyers have significant experience in defending against class action litigation, providing regulatory compliance counseling, and participating in the contract negotiation process. In addition, we regularly collaborate with the firm's non-lawyer lobbyists in developing regulatory and political solutions to our clients' needs.
 

    • Experience
      • Obtained summary judgment for health insurer in ERISA matter where plaintiff challenged level of care decision involving behavioral health benefits. Court concluded that ERISA plan allowed insurer to delegate discretionary authority to its designee, that designee was allowed to rely on its level of care guidelines in reaching its decision, and that the decision following an external review was not a merely ministerial act which stripped insurer of its discretion. Court further concluded that, while the insurer’s decision was reasonable and free of conflict under the arbitrary and capricious standard of review, the decision was also de novo correct. 2018 U.S. Dist. LEXIS 26811 (S.D. Fla. Feb. 16, 2018).

      • Appealed before Connecticut Supreme Court an issue of first-impression regarding reasonableness of utilization review criteria used to make medical necessity decisions for Medicaid recipients in the early prevention, screening, diagnosis and treatment (EPSDT) program.

      • Represented a health insurer concerning its administration of the Connecticut Medicaid program, including matters relating to provider reimbursement and compliance with Connecticut's Freedom of Information Act requirements, an area in which Robinson+Cole litigated the leading cases involving Medicaid managed care organizations (MCOs).

      • Represented a managed care insurer that issued a group health plan to an employer that subsequently entered into bankruptcy. We handled all aspects of the Chapter 11 bankruptcy proceeding on behalf of the managed care insurer, including negotiating the inclusion of the managed care insurer in the court's critical vendor payment order to allow premiums to continue to be paid from the debtor's assets, payment of all accounts receivable due and owing to the insurer, and timely assumption of the group health plan insurance contract by the bankruptcy trustee.

      • Arbitrated multi-million dollar disputes between Medicare Advantage Organizations (MAOs) and their subcontractors relating to federal regulatory and reimbursement issues.

      • Worked with special investigations units (SIUs) in managing investigations, pursuing recovery actions, and coordinating with law enforcement and other regulatory agencies.

      • Advised national pharmacy benefit manager (PBM) on federal regulatory requirements regarding the authorization, processing, and management of pharmacy claims. Revised client's internal policies and processing systems to comply with regulations while meeting needs of members and provider community.

      • Successfully defended member class action alleging that an MCO improperly sought subrogation recoveries for medical costs paid in personal injury actions. Plaintiffs sought to certify a class of thousands, including all insureds from whom the MCO sought or may in the future seek reimbursement of medical costs. After extensive class certification hearings, succeeded in limiting size of class certified to under 200 members. Claims were settled through private mediation on a favorable basis.

      • Defended managed care organization in lawsuit involving the termination of a risk-sharing arrangement with a capitated contractor. Claims involved potential monetary exposure in excess of $37 million. Negotiated favorable settlement. 

      • Represented a Medicaid MCO in a successful appeal before the Connecticut Supreme Court involving the reasonableness of utilization review criteria used to make medical necessity decisions. Obtained ruling that MCO's criteria for determining whether orthodontic treatment was medically necessary for Medicaid recipients in the early prevention, screening, diagnosis, and treatment program were appropriate and provided recipients with all covered benefits under the federal Medicaid Act.

      • Defended an MCO against member class action (100,000+ class members) challenging prompt provision of services and notification of denied and terminated benefits. Succeeded in demonstrating the constitutionality of company policies in two preliminary injunction hearings through extensive analysis of due process precedent and detailed testimony regarding plan programs and policies. Successfully negotiated settlement involving no monetary payment to class members or to class counsel.

      • Represented an MCO in a class action lawsuit brought by nonphysician providers alleging that the state unfair insurance practices act requires MCOs to reimburse all providers at the same rates regardless of license or specialty.

      • Successfully prosecuted a fraud recovery action against chiropractors and medical doctors who had engaged in extensive fraudulent billing practices. Obtained a significant recovery in settling the matter while simultaneously settling two Connecticut Unfair Trade Practices Act suits for no payment.

      • Defended an MCO in a class action lawsuit brought by providers and an independent physician association (IPA) alleging that the MCO failed to properly administer a risk-sharing arrangement over a three-year period. Claims involved potential monetary exposure in excess of $25 million. Negotiated settlement involving no monetary payment to class.

      • Represented managed care organization in multidistrict litigation brought by physician and health plan member classes alleging market conduct violations.

      • Health Care and Insurance Industry

      • Represents and advises managed care companies, health insurers and third-party administrators in reimbursement, benefits and payment policy disputes with providers, subscribers and medical associations.

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    • News
      • February 22, 2021

        Greg Bennici Profiled in Fairfield County Business Journal’s 2021 “40 Under Forty” Issue

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      • January 29, 2021

        Robinson+Cole’s Recent Lateral Hires Profiled in Law360 Article

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      • January 26, 2021

        Robinson+Cole Continues Growth in Philadelphia

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      • December 16, 2020

        Jean Tomasco Authors ERISA Report Article on COVID-19’s Impact on COBRA Continuation Coverage

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      • October 8, 2020

        Robinson+Cole Recognized in Benchmark Litigation

      • September 24, 2020

        Robinson+Cole Welcomes Matthew Mazzola as Partner in Managed Care + Employee Benefit Litigation Group

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      • August 14, 2020

        Milanna Datlow Authors DRI Article on Coverage Under Private Group Health and Disability Plans as a Result of COVID-19

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      • May 13, 2020

        Milanna Datlow Authors DRI Article on Hospital Risk Management Issues

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      • January 3, 2017

        Robinson+Cole Welcomes New Litigation Partner

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    • Publications + Presentations
    • "What Every Litigator Should Know About ERISA," presented by Patrick W. Begos (2/12/2021)
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      "Implications of COVID-19 for Group Health and Disability Plans, Including COBRA," co-presented by Milanna Datlow and Jean E. Tomasco, at the Managed Care + Employee Benefits Summit. (October 1, 2020)
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      "Navigating Coverage Considerations for Behavioral Therapy and Substance Abuse Treatment," presented by Michael H. Bernstein, as part of the American Conference Institute's two-day virtual 11th Annual Advanced Forum on Managed Care Disputes and Litigation. (7/23/2020)
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      "Into the Wilderness: Recent Developments in Federal Parity Act Litigation," presented by Jeannine C. Jacobson, presented at the ABA's "46th Annual TIPS Mid-Winter Symposium on Insurance and Employee Benefits (1/17/2020)
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      "Fiduciary Status of Plan Service Providers: Overview and Trends," co-presented by Jean E. Tomasco and Latanae L. Parker, at Robinson+Cole's Managed Care and Employee Benefit (MCEB) Summit (9/25/2019)

      "Budding Industry: Litigation Trends for the Emerging Cannabis Market," presented by Katherine M. Katchen, presented to the Association of Corporate Counsel of America, Greater Philadelphia Chapter, Litigation Institute (October 2019)
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      "Managing Care: E.R. Reimbursement and Other Participating Provider Issues," presented by Theodore J. Tucci, presented at the Defense Research Institute's Life, Health, and ERISA Seminar in Chicago, Illinois. (4/3/2019)

      "Conversion, Portability, and Evidence of Insurability: Mistakes Will Be Made," presented by Jeannine C. Jacobson, at the Defense Research Institute's Life, Health, Disability and ERISA seminar in Chicago, Illinois. (4/3/2019)
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      "Conversion, Portability and Evidence of Insurability: Mistakes Will Be Made," authored by Jeannine C. Jacobson (4/3/2019)
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      "Brushes with Government Entities," presented by Katherine M. Katchen, during the Blue Cross Blue Shield 2019 National Summit (April 2019)
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      "Privacy and the Evolving Litigation and Compliance Landscape," presented by Katherine M. Katchen, at the Association of Corporate Counsel of America, Greater Philadelphia Chapter, In-House Counsel Conference (April 2019)
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      "Brushes with Government Entities: Ethical Considerations in Dealing with Everything from Third-Party Subpoenas to Election Day Campaign Promises," presented by Katherine M. Katchen, to the Association of Corporate Counsel of America, Delaware Valley Chapter (December 2018)
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      "Managed Care Litigation Update 2017," co-presented by Jean E. Tomasco and Theodore J. Tucci, a webinar for a firm client in the specialty risk insurance industry. (4/19/2017)
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      "Cover Your Assets: Drafting and Enforcing Restrictive Covenant Agreements," presented by Katherine M. Katchen, to the Association of Corporate Counsel of America, Delaware Valley Chapter (August 2016)
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      "Managed Care Litigation Update 2016," co-presented by Jean E. Tomasco and Theodore J. Tucci, a webinar for a firm client in the specialty risk insurance industry (3/30/2016)
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      "ERISA is 40....But is it Still Fabulous?" presented by Katherine M. Katchen, at the Blue Cross Blue Shield 2015 Blue National Summit (April 2015)
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      "Managed Care Litigation Update 2015," co-presented by Theodore J. Tucci and Jean E. Tomasco, a webinar for a firm client in the specialty risk insurance industry (4/8/2015)
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      "Changing Provider-Payer Relationship Post-ACA," presented by Katherine M. Katchen, to the American Bar Association Health Law Section at the 16th Annual Conference on Emerging Issues in Healthcare Law (March 2015)
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      "2014 Update & Trends in Shareholder Law & Litigation," presented by Katherine M. Katchen, to the Association of Corporate Counsel of America, Delaware Valley Chapter (April 2014)
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      "Regulatory, Legal & Political Issues for FDA Regulated Companies: Corporate Officer Responsibilities and Liability," presented by Katherine M. Katchen (February 2012)
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      "Responding to Government Investigations and Preparing for Follow-on Litigation," presented by Katherine M. Katchen, to the Blue Cross Blue Shield Association at the 44th Annual Lawyer’s Conference (May 2010)
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      "Obama’s Antitrust Watchdogs: Has the Bite Been Worse Than the Bark? Trends in Private Antitrust Litigation," presented by Katherine M. Katchen, to the Pennsylvania Bar Institute, Business Law Institute (November 2009)
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      "Antitrust Compliance: Tips for In-House Counsel to Minimize Antitrust Risk," presented by Katherine M. Katchen, to the Association of Corporate Counsel of America, Delaware Valley Chapter (May 2009)
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      "Recent Trends in DOJ and SEC Actions Against In-House Counsel," presented by Katherine M. Katchen, to the Association of Corporate Counsel of America, Delaware Valley Chapter (April 2009)
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      "Personal Liability Risks Facing In-House Counsel," presented by Katherine M. Katchen, to the Association of Corporate Counsel of America, Delaware Valley Chapter (April 2007) and the Pennsylvania Bar Institute’s 12th Annual Business Lawyer’s Institute (Nov. 2006)
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Our Team

Chair

Members