Managed Care and Health Insurance

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 a depth of experience and a real understanding of the managed care and health insurance business. Robinson+Cole has both: we know the health benefits industry.

We have represented managed care and health insurance clients for more than two decades as outside general counsel in litigation, corporate, and regulatory matters. Our clients include national managed care organizations operating public and private sector health plans, health insurers in the individual and small group markets, pharmacy benefit managers, excess loss carriers, third-party administrators, and self-funded employer groups. We have also acted as general counsel to the Connecticut Life & Health Insurance Guaranty Association for over ten 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 nonlawyer lobbyists in developing regulatory and political solutions to our clients' needs.

We regularly represent managed care and health insurance clients in matters involving the following:

  • administrative hearings before state and federal regulators
  • dual eligibles
  • prompt pay statutes
  • any willing provider laws
  • Medicaid-managed care
  • Medicare Part D
  • provider disputes
  • member disputes
  • market conduct litigation
  • subrogation and anti-subrogation legislation
  • ERISA compliance and litigation
  • out-of-network provider reimbursement
  • balance billing laws
  • pharmacy benefit management
  • utilization review requirements
  • state licensure
  • SIU investigations
  • antitrust government investigations
  • network contracting

    • Experience
      • Managed Care

      • 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.
      • Representation as outside counsel for 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.
      • Representation as Health Net of the Northeast's lead litigation and regulatory counsel when Health Net administered the Connecticut Medicaid program. As regulatory counsel, advised Health Net regarding its legal obligations to the Medicaid state agency and represented the client in numerous administrative matters.
      • Representation of a managed care insurer that issued a group health plan to an employer that subsequently entered into bankruptcy. On behalf of the managed care insurer, Robinson & Cole handled all aspects of the Chapter 11 bankruptcy proceeding, including negotiation of 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.
      • We work collaboratively with SIUs to help them manage investigations, pursue recovery actions, and coordinate with law enforcement and other regulatory agencies.
      • Advised national 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.
      • Defended member class action alleging that 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 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 managed care organization 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 managed care organization 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.
      • Defended a plan sponsor in a case brought by retired employees who claimed that the termination of their health benefit coverage violated ERISA. Following informal discovery, we obtained summary judgment on all of plaintiffs' claims and thereby eliminated potential liability to hundreds of other retirees.
      • Represent a managed care organization in a class action lawsuit brought by non-physician providers alleging that the state unfair insurance practices act requires MCOs to reimburse all providers at the same rates regardless of license or specialty.
      • Prosecuted a fraud recovery action against chiropractors and medical doctors who had engaged in extensive fraudulent billing practices. Obtained significant recovery for the client in settling the matter while simultaneously settling two Connecticut Unfair Trade Practices Act suits for no payment.
      • Defended managed care organization against class action lawsuit brought by providers and IPA alleging that the MCO failed to properly administer a risk-sharing arrangement over 3 year period. Claims involved potential monetary exposure in excess of $25 million. Negotiated settlement involving no payment of monetary relief to class.
      • Represented managed care organization in multidistrict litigation brought by physician and health plan member classes alleging market conduct violations.
      • Managed Care and Health Insurance

      • Provide regulatory and risk management counseling to administrators of special needs plans for dually eligible Medicare/Medicaid enrollees.
      • Representation of Medicare Advantage Organizations (MAO) in administrative litigation, arbitration, and regulatory matters. Provided legal advice to MAOs regarding legal issues, such as Medicare marketing guidelines, broker compensation arrangements, risk-based provider contracting, coordination of benefits, and compliance with anti-kickback safe harbors.
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    • News
      • January 3, 2017

        Robinson+Cole Welcomes New Litigation Partner

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        • View article

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