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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:
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 2018 Cumulative Supplement discusses:
Disputes involving: medical necessity determinations; benefit exclusions on mental health disability, autism spectrum disorder treatment, and gender dysphoria; an anti-abortion group’s challenge to the contraceptive mandate exemption; and bad faith and negligent credentialing cases
Provider versus payor issues such as line item denials of charges, and patient actions brought for charging more than payor contract rates
Updates on pay for performance programs (P4P), Hospital Value-Based Purchasing (VBP), the Merit-based Incentive Payment System (MIPS) and Advanced APM
In antitrust litigation, whether a hospital system unreasonably restrained trade through steering provisions incentivizing consumers for using healthcare providers in certain tiers or plans
The impact of regional variations in legal standards in class actions
Federal health program topics such as beneficiary suits against MCOs for failure to cover benefits, or for failure to provide benefits ordered in a fair hearing, in addition to MCO contract bid protests based on the use of third-party materials in bids
Application of the Second Circuit’s Montefiore test regarding ERISA preemption of state regulatory power, and the Eleventh Circuit’s “rate of payment” versus “right of payment” test
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