Managed Care Litigation, Second Edition, with 2018 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.



Meet The Authors

David M. Humiston
Editor-in-Chief (Main Volume)
Michael H. Bernstein
Editor-in-Chief (2017 Cumulative Supplement)


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 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



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. Humiston is a retired partner from the Los Angeles office of Sedgwick LLP, and former chair of the firm’s Healthcare Practice Group.
Michael H. Bernstein is a partner in the New York office of Robinson & Cole LLP, and is a member of the firm’s Health and Benefits Litigation Team.


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