Healthcare Disputes

Navigating the healthcare disputes landscape can be a complex journey.

We assist payors, physician platforms, pharmacies, disease management companies, healthcare technology companies, and private equity investors through the complexities of healthcare disputes.

Our deep industry knowledge allows us to craft practical solutions for your most challenging disputes. Members of our team – which include lawyers from DLA Piper’s Regulatory and Government Affairs and Litigation, Arbitration, and Investigations teams– have served in senior positions at the Centers for Medicare & Medicaid Services (CMS), the Food and Drug Administration (FDA), as well as federal and state prosecutors and senior in-house counsel.

We work with our clients to develop and defend compliant revenue maximization strategies, helping them maintain profitability and compliance throughout the business lifecycle.

Our experience representing clients in multiple areas includes responding to regulatory challenges, resolving government investigations, defending single plaintiff and class action litigation, prosecuting affirmative litigation, and reducing risk.

Healthcare litigation

• One of the nation's largest healthcare payors, in ongoing multi-jurisdictional civil litigation arising from a high-profile healthcare fraud prosecution, involving complex RICO, immunity, and preemption issues, and securing significant victories including removal to federal court and dismissal of multiple claims.
• A national health insurer, in a putative class action challenging out-of-network reimbursement methodologies.
• A major health insurer, in multiple class actions and individual lawsuits involving medical necessity and experimental or investigational treatment coverage determinations.
• A national health insurer, in successfully defending a putative class action brought on behalf of mental health professionals.
• A health insurer, in successfully arguing that claims asserted under Illinois privacy laws were preempted by ERISA.
• A health plan, in obtaining dismissal of a vicarious medical malpractice action.
• A leading health insurance organization, in successfully defending a federal antitrust action under the Sherman Act.

Healthcare investigations

• A major healthcare payor, in civil litigation stemming from a criminal healthcare fraud investigation involving rural hospitals, requiring coordination of parallel litigation and fraud-related defense strategies.
• A health plan, in litigation seeking recovery of overpayments from an emergency physician practice arising from systemic upcoding practices embedded within a practice management system.
• A health plan, in arbitration involving medically unnecessary services, improper provider licensing, and related state and federal healthcare compliance issues.
• Health plans and payors, in fraud, abuse, and compliance-related disputes involving provider billing and reimbursement practices.

Medicare and Medicaid audits

• A health plan, in advising on the use of statistical sampling methodologies in claims audits.
• A health plan, in recovering claims payments made after a provider became ineligible to participate in a Medicaid program.
• A health plan, in counseling regarding Medicaid claims payment obligations while a provider was under investigation by the Kentucky Department of Health and Human Services.
• Health plans and managed care organizations, in Medicare and Medicaid reimbursement disputes, overpayment recovery efforts, and audit-related challenges.
• Health plans, in disputes involving provider reimbursement methodologies, capitation calculations, prompt-pay requirements, and managed care payment obligations.