Managed Care

GrayRobinson's managed care lawyers have decades of experience representing all types of payors and managed care organizations and similar entities, including health plans and health insurers, HMOs, PPOs, TPAs, MAs, PDPs, EPOs, HCOs and self-funded plans. The range of services includes reimbursement, operations, litigation, regulatory and compliance issues, lobbying, contracting, risk management and representation at administrative hearings. We can assist our managed care clients on issues such as non-contracted-provider payment practices, disputed claims, capitation reconciliation, economic credentialing, any-willing provider, contract negotiations, silent PPOs, and tiered networks. Regulatory issues on which we can assist include formation, licensure, and certification of managed care organizations and provider networks.

  • Provider and Member Disputes/ERISA and Non-ERISA

    GrayRobinson represents managed care organizations in benefits disputes in all forums: state court, federal court (mostly based on ERISA preemption) and arbitration though the American Arbitration Association, American Health Lawyers Association or JAMS. GrayRobinson has a concentrated team of ERISA litigators with in-depth experience defending the managed care industry. Our managed care lawyers not only know the law; they know the industry and its trends. GrayRobinson recognizes the impact any single case can have on the company as well as its potential effect on the industry. With this industry knowledge, GrayRobinson is also uniquely equipped to advise and represent managed care clients regarding appeals

  • Class Action Litigation

    As the operations of the managed care industry continue to be challenged through class action litigation, GrayRobinson’s managed care lawyers know how to respond. Working closely with managed care clients, GrayRobinson works to defeat class certification while evaluating the merits of the underlying claims.

  • Public Sector Plans

    In addition to defending claims concerning commercial plans, GrayRobinson’s managed care lawyers have decades of experience working with Medicare Advantage plans, Medicaid HMO’s and plans covering members of Florida Healthy Kids. In an already highly regulated industry, these government-funded plans are subject to additional scrutiny by administrative agencies. To represent these entities requires unique knowledge and experience. Our representation of these entities includes litigation, internal investigations and working with the regulatory agencies on compliance issues.

  • Medical Management and Credentialing

    With experience defending medical malpractice claims, our managed care lawyers understand the medical issues involved in some of these managed care disputes and know how to work with medical experts in handling these matters. This additional knowledge only adds value to the representation of managed care clients. This medical background, coupled with the understanding of how managed care plans operate, allows GrayRobinson to work with clients on case management, credentialing and utilization management issues.

  • Special Investigations Unit and Subrogation

    Our managed care lawyers also work closely with our clients' Special Investigations Units on fraudulent and abusive billing and subrogation departments to protect the client's assets and help seek reimbursement for overpayments