Managed Care Litigation, Second Edition, with 2016 Cumulative Supplement

This essential reference is written specifically for practitioners who handle managed care disputes to help them rapidly focus on key issues and expertly advise their clients. The treatise covers typical disputes, reimbursement issues, state regulations, health plan liability laws, external review laws and health insurance exchanges, and class action lawsuits and arbitration, settlement, and discovery issues.



David M. Humiston


Practice-oriented guidance for litigating within the managed care industry

Myriad potential litigation issues were introduced by the Affordable Care Act (ACA), as health plans and other managed care organizations will have to comply not only with state mandated benefits but with federally mandated benefits as well. After 2014, the size of the health coverage market, especially for the individual coverage, will increase as higher-risk individuals are able to obtain coverage regardless of health status and lower-risk individuals elect to pay premiums rather than penalties. The influx of insured patients into the managed care system will result in more litigation and an array of new issues.

Managed Care Litigation, Second Edition is a practical, authoritative reference written specifically for practitioners who handle managed care disputes to help them rapidly focus on key issues and expertly advise their clients. The treatise offers in-depth analysis of all the important issues in managed care litigation, providing both a basic overview and a comprehensive examination of legal issues. The book provides useful guidance on:

  • Typical disputes, such as benefits coverage issues, utilization management, and contractual claims between payors, providers, and patients
  • Reimbursement issues, including billing and coding and prompt-pay statutes
  • State regulations and insurance administrative processes
  • Health plan liability laws, ACA compliance, and issues pertaining to medical loss ratios
  • External review laws and health insurance exchanges
  • Managed behavioral health care litigation issues and mental health parity
  • Litigating disputes arising under federal health programs, including Medicare, Medicaid, FEHBP, and TRICARE, as well as Federal False Claims Act, Anti-Kickback, and Stark issues
  • Antitrust litigation, including unfair trade practices, exclusionary conduct, most-favored nation clauses, and anti-competitive actions
  • Class action lawsuits and arbitration, settlement, and discovery issues
  • ERISA litigation and preemption strategies
  • Formation and operation of managed care network organizations, ACOs and value-based provider reimbursement, and pay for performance issues

This timely reference is an excellent springboard to drafting pleadings or advisory memoranda and is organized so that both in-house and outside managed care counsel and executives can quickly access the information they need, review the legal theories and processes involved, and get up to speed on the case law.


The 2016 Cumulative Supplement adds discussion of: 

  • The Supreme Court decision in Campbell-Ewald Co. v. Gomez regarding unaccepted offers of judgment in class actions

  • U.S. Circuit Court decisions considering the impact of the Supreme Court’s Hobby Lobby decision

  • The final rule implementing the Comprehensive Care for Joint Replacement (CJR) payment model, under which hospitals will receive bundled payments

  • Litigation related to: prompt pay statutes; failure to maintain adequate patient health care records under state law; group boycott claims; and the extent to which federal civil rights protections apply to Medicare Advantage plans

  • Increasing activity from some state Attorney Generals and administrative agencies over changes in provider networks

  • State intervention in Medicare Advantage plan/provider relations

  • Updates to appendices covering federal class action cases, and state external review laws and procedures


Bloomberg BNA authors and editors are practicing professionals with insider perspectives and real-life experience. Learn more about this book’s authors and editors.
David M. Humistonis a retired partner from the Los Angeles office of Sedgwick LLP, and former chair of the firm’s Healthcare Practice Group.


View full tables of contents and read the book’s preface or introduction.