Managed Care and ERISA
Cooper & Scully has served the managed care industry in consulting and litigation for 20 years. Our attorneys represent health plans, insurance companies, provider organizations, networks, third party administrators (TPAs), as well as self-funded employer plans and their fiduciaries. Cooper & Scully has represented managed care and ERISA clients in more than 1,000 individual and class action matters pending in California, Texas and nationwide.
We have litigated dozens of cases involving allegations against managed care organizations for bad faith denial of benefits, rescission of benefits, and breach of contract. We regularly succeed in bad faith cases brought by the nation's leading bad faith attorneys against insurers. We are familiar with virtually every variation of the bad faith case, including the following:
- Claims that an integrated health care system internalized a program for the sole purpose of cutting costs associated with referrals to non-plan providers
- Claims that an integrated health plan had utilization review procedures that prevented patients from obtaining medically necessary care from non-plan providers for the sole intent of saving money
- Claims that individual medical providers were incented by a health plan to deny costly, but medically necessary, treatments for the purpose of saving money
- Claims that member benefits and coverage were rescinded in their entirety based on illegal, post-claims underwriting
- Claims that a class of people were routinely denied benefits under a health insurer's Evidence of Coverage (EOC) in violation of state mental health parity law
Business and Corporate Structure Litigation
Litigation involving managed care entities often implicates regulatory and other attacks on the business arrangements and corporate structure of the corporate parties, beyond simple contract or business disputes. Handling these types of claims requires a working knowledge of the legal and regulatory framework applicable to our managed care clients. Our attorneys have in-depth knowledge of the federal and state laws and regulations, including the following frequently litigated laws and regulations:
- Medicare/Medicaid and CMS regulations and guidelines;
- FEHBA and OPM regulations and guidelines;
- Federal and State HMO acts, laws and regulations;
- Patient Protection and Affordable Care Act (PPACA)
- Knox-Keene Act laws and regulations;
- Texas Department of Insurance laws and regulations; and
- Texas Worker’s Compensation laws and regulations.
Contract Disputes and Business Torts
Managed care involves a complex array of contracts and business relationships. In addition to transactional assistance and consulting on these topics, Cooper & Scully frequently represents managed care clients when contractual and business relationships end up in litigation. We handle a variety of claims for our managed care clients, ranging from contractual disputes to business torts, including breach of contract actions, tortuous interference with contracts and prospective contracts, quantum meruit actions, actions for equitable relief such as injunctions and intellectual property lawsuits dealing with allegations of trade secret misappropriation.
We regularly defend hybrid contract, statutory and/or common law claims attempting to increase or recover reasonable and customary payments or otherwise attack payment methodologies. We have a significant practice in handling provider reimbursement and other contractual disputes pertaining to medical and hospital service reimbursement claims. Our federal experience with ERISA, FEHBA and Medicare provides us with a significant and cost-effective advantage in briefing and addressing federal preemption issues in the context of these cases.
We have a thorough understanding of applicable federal and state laws and regulations, including California’s Knox-Keene Act and Insurance Code, as well as the inner workings of state and federal agencies that regulate managed health care. We are frequently called upon to handle regulatory matters that arise in the face of threatened or pending litigation and we take great care in ensuring that the regulatory proceedings and pending litigation are in sync with client goals. Our experience includes a wide array of regulatory representation of managed care clients, including the following examples:
- Centers for Medicare and Medicaid Services (CMS);
- California Department of Managed Health Care (DMHC);
- Office of Civil Rights (OCR);
- Texas Department of Insurance;
- Texas Worker’s Compensation Board;
- Office of Personnel Management (OPM);
- United States Department of Labor;
- Employee Benefits Security Administration (EBSA);
- State Medical Boards;
- State Pharmacy Boards;
- State Nursing Boards; and
- Quasi-governmental regulatory bodies such as the United Network of Organ Sharing (UNOS).
ERISA and Employee Benefits
We also have a busy ERISA and employee benefits litigation practice on behalf of health care clients and networks. A significant amount of the work involves claims for employer-sponsored benefits in a health care related setting. Cooper & Scully regularly handles direct benefit claims and defenses, preemption application issues, and breach of fiduciary duty claims. Our clients range from the large non-profit health plans to small, self-funded employer sponsored plans. Our health care focus is in addition to our ERISA and employee benefits practice involving other types of employee benefits and pensions.