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.
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
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.
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.
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.
Obtained first ruling nationwide holding that COVID test providers cannot assert a private right of action for payment under the Families First Coronavirus Response Act or the Coronavirus Aid, Relief, and Economic Security Act