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Practices

Managed Care

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Baker Donelson's attorneys have years of hands-on experience – both as in-house and outside counsel – serving as trusted advisors to for-profit and not-for-profit providers across the full spectrum of health care services.

Why Baker Donelson?


More than 200 attorneys and advisors serving the health care sector
Ranked as a top health law firm by Modern Healthcare, Best Law Firms®, Chambers USA, ABA, and AHLA
Extensive experience working with HHS, CMS, DOJ, FEMA, and other federal government agencies
5 former American Health Law Association presidents who served while practicing at Baker Donelson

Practice Overview


Managed care is one of the most heavily regulated sectors of the health care industry, and every state has its own rules. Providers need sophisticated advisors who can respond quickly and adeptly to the complex and evolving legal, regulatory, and business issues inherent in working with managed care organizations (MCOs). Baker Donelson's attorneys have years of hands-on experience – both as in-house and outside counsel – serving as trusted advisors to for-profit and not-for-profit providers across the full spectrum of health care services.

With mounting pressure to slash costs, the aggressive techniques and strategies of the managed care sector – once confined to health maintenance organizations – have become ubiquitous. Baker Donelson provides strategic counsel to leaders in the health care industry as they navigate private and public payors' persistent efforts to reduce payment to providers. We regularly represent clients in regulatory, compliance, and operational issues related to managed care.

We know the law. And we know the business of health care.

Contract Development and Negotiation

Negotiating contracts with MCOs presents complex issues of responsibility, liability, and risk, with overlapping federal and state laws and regulations to consider. Baker Donelson's attorneys have deep experience negotiating a wide range of agreements, from hospital system contracts to contracts involving health plans and physician groups and alternative health care delivery organizations. As advisors to numerous regional and national health care providers, our objective is to help clients structure their agreements to effectively meet their business, operational, and compliance needs.

Litigation

Litigation against MCOs is on the rise nationwide, with payors using their market leverage to force providers into accepting pennies on the dollar for medically necessary, life-saving care. Baker Donelson's managed care litigation attorneys are at the forefront of the fight for providers against the nation's largest payors. Our in-depth knowledge of reimbursement practices, Medicare and Medicaid rules and regulations, health care operations, contract negotiations, and the rigid billing practices of MCOs position our litigators to aggressively protect clients' interests in all manner of litigation involving managed care, from payor-provider disputes (both in- and out-of-network), to False Claims Act litigation, to class actions and Employee Retirement Income Security Act (ERISA) litigation.

Our attorneys are particularly experienced in handling reimbursement-related disputes on behalf of health care providers against payors, including Medicare Advantage Organizations, Medicaid MCOs, and government payors. The team has represented health care providers bringing payment disputes in federal and state courts, the Medicare Provider Reimbursement Board, state Medicaid appeals agencies, and national arbitration associations. Our team understands and has demonstrated – through measurable results – that there is a path forward for providers who render medically-necessary care to patients yet have been subject to the questionable tactics and strategies of MCOs involving the improper denial, underpayment, and nonpayment of claims for medically-necessary items and services.

Our extensive experience includes representation of:

  • Academic medical centers
  • Anesthesia providers
  • Behavioral health providers
  • Children's hospitals
  • Dialysis providers
  • Emergency service providers
  • Home health providers
  • Hospice providers
  • Hospitals and health systems
  • Long term care providers
  • Provider networks
  • Telehealth providers
  • Represented a large health system in a dispute adverse to a national Medicare Advantage Organization (MAO) involving improperly downgraded claims and denials of inpatient admission, resulting in a favorable settlement for the health system.

  • Represented a multi-hospital health system in a dispute against a national health insurer related to improper inpatient denials, Diagnosis-Related Group (DRG) downgrades, and other underpayments resulting in an eight-digit settlement and favorable contract changes going forward.

  • Represented a multi-state hospital system in 340B underpayments.

  • Represented a large academic medical center in a payor dispute adverse to a national MCO for non-payment/underpayment for inpatient behavioral health services.

  • Represented a large academic medical center in a dispute adverse to a national MAO and MCO involving numerous improper reimbursement and contractual practices, including underpayments.

  • Represented a behavioral health provider in alleged overpayments arising from post-payment review adverse to a national Medicaid managed care company, resulting in a complete reversal of the overpayments and contract amendments.

  • Represented a regional home health provider in arbitration adverse to a national MAO involving improper denial of claims based on coding, timely filing, medical necessity, and additional issues, resulting in favorable settlement for the provider.

  • Represented a national hospice provider in a Zone Program Integrity Contractor (ZPIC) audit, resulting in a seven-figure overpayment and appeals to the Administrative Law Judge (ALJ) and Medicare Appeals Council (MAC).

  • Represented large, multi-state skilled nursing facilities before the Provider Reimbursement Review Board (PRRB) to challenge Medicare Quality Reporting Program (QRP) Annual Payment Update (APU) reductions.

  • Represented a large, multi-state rehabilitation hospital before the Administrative Law Judge to challenge Medicare hospital price transparency penalties.

  • Represented a multi-hospital health system in a dispute with a national Medicare Advantage MCO regarding improper denials and downgrades of inpatient claims.

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