K&L Gates has a significant number of lawyers in numerous jurisdictions who are experienced in representing health care providers in all types of payor disputes.

Our representative clients run the spectrum and include providers such as hospital systems (including AMCs), ambulatory surgery centers, behavioral health providers, freestanding diagnostic and treatment facilities, nursing facilities, adult care facilities, continuing care retirement facilities, home health and hospice agencies, dialysis providers, clinical laboratories, and physician groups.

Our payment dispute experience includes (but is not limited to) the following categories:

  • Disputes against various commercial insurance payors, including:
    • State court and federal court lawsuits over contract term interpretations
    • ERISA and non-ERISA claims
  • Disputes against various managed care organizations, including:
    • Conventional managed care contracting disputes (including right of payment and rate of payment disputes)
    • Disputes with Medicare Advantage Organizations (“MAO”) over Medicare Advantage (“MA”) contract interpretation issues
    • Suits under various state laws requiring specific reimbursement levels for certain types of services
    • Suits challenging whether purported PPOs satisfy state statutory PPO definitions
  • Out-of-network provider versus payor disputes, including issues such as:
    • Copayment and other cost sharing waivers
    • ERISA and non-ERISA claims
    • Usual, customary, and reasonable charges
    • Whether a treatment is experimental or investigational
  • Disputes against State Medicaid Agencies, including:
    • Agency recoupment efforts
    • Agency payment denials
    • Cost report challenges
    • Enrollment disputes
  • Appeals of CMS Medicare and State Medicaid audits
  • False Claims Act disputes
  • Medicare disputes before the Departmental Appeals Board, Medicare Administrative Contractors, the Medicare Appeals Council, and Federal Administrative Law Judges (“ALJs”)