Managed Care Disputes and Litigation

Advanced MCO Think-tank on Litigating Fraudulent Billing and Recovering Funds

• Learn from the experience of carriers that have been proactive in initiating actions against providers for fraudulent billing
• Gain insight into trends in instituting audit provisions and how best to manage relationships with providers and third parties in the auditing process
• Examine and challenge billing practices in an efficient manner, demanding transparency while containing administrative burdens
• Know how to uncover common forms of fraud, including falsified diagnoses, unnecessary treatment, and upcoding
• Identify successful approaches and pitfalls to avoid in attempting to recover payment

Navigating the Future of American Healthcare: What Litigators Should Know about Value-Based Reimbursement

• Learn how the shift to a value-based contracting is changing the nature of relationships between payors and providers
• Recognize recent regulatory changes aiming to reduce impediments to value-based care, such as the Department of Health and Human Services (HHS)’s reforms to the Stark Law (which prohibits physicians from referring patients to entities with which they and their family have a financial relationship) and the Federal Anti-Kickback Statute (AKS)
• Anticipate disputes that may arise in relation to this payment methodology
• Gain the knowledge you need to successfully manage the complexities of a highly technical and multi-variable model while staying compliant and avoiding liability

Registration Opens and Refreshments Served

Opening Remarks from the Co-Chairs

In-house Counsel Roundtable: Managing Key Legal Challenges in Managed Care Operations

• Gain insight into the main day-to-day preoccupations of in-house counsel at leading managed care organizations (MCOs)
• Analyze the trend in Medicaid expansion by states and how MCOs will be affected
• Acquire best practices on collaborating with outside counsel
• Learn how technological solutions are enabling greater efficiency in discovery and dispute resolution and often reducing need to retain outside counsel
• Explore the ways in which leading MCOs are deploying artificial intelligence to monitor patient behavior and avert need for costly treatment
• Institute an effective data sharing and analytics strategy for providers to derive actionable patient insights and make data-driven decisions in treatment
• Get MCOs’ perspectives on legislative developments and enforcement activity over the past year

Assessing the Impact of Surprise Billing Legislation on Providers and MCOs

• Stay on top of legislation relating to out-of-network balance billing (or “surprise” billing) in states including New York, Connecticut, and Oregon
• Know what to expect from similar proposed legislation at the federal level (H.R.861)
• Understand how managed care agreements between payors and providers are likely to evolve in a context of decreased patient liability
• Hear about legislative and industry efforts to decrease the cost of healthcare, which may enable more contractual arrangements with payors and decrease out-of-network care delivery
• Understand objections to the legislation by industry groups including the Federation of American Hospitals (FAH) and the American Hospital Association (AHA)
• Get insight into the current status of challenges to the constitutionality of surprise billing legislation

Networking Refreshment Break

Regulatory State of the Union for Managed Care

• Hear about the state of challenges to the Affordable Care Act (ACA)’s constitutionality
• Learn how to navigate the complex sea of new ACA-related regulations issued by Centers for Medicare and Medicaid Services (CMS)
• Examine the status of the multi-billion-dollar dispute over the ACA’s risk corridor program currently before the Supreme Court (Maine Community Health Options v. United States)
• Assess trends in insurer-HHS disputes over unpaid cost sharing reduction (CSR) payments
• Understand how HHS’ reforms to the Stark Law and the Federal AKS impact providers and the managed care space more broadly
• Get informed about pricing transparency legislation for providers and litigation by hospital associations challenging its constitutionality
• As an insurer, know what to expect should the Transparency of Coverage rule proposed by HHS, the Department of Labour, and the Department of the Treasury be implemented
• Understand the implications of CMS’ proposed rule on Medicaid Fiscal Accountability
• Gain insight into new legislation and regulations governing PBMs, including transparency requirements

Spotlight on Antitrust: How Health Insurers Should Approach Hospital Mergers

• Gain insight into recent antitrust investigations and enforcement proceedings against providers, which are merging at a rapid pace
• Hear how regulatory scrutiny is derailing merger plans, such as that of UnityPoint Health and Sanford Health
• Examine the consequences of consolidation, including excessive power among hospital systems and higher pricing
• Determine avenues through which health insurers can prevent undue hospital consolidation, as employers and individuals rely on them to negotiate competitively priced hospital care
• Identify effective advocacy mechanisms for insurers and explore ways in which they can respond when contacted by federal agencies or state AGs

Networking Lunch

Analyzing the Legal Implications of Vertical Integration in the Healthcare Industry

• Learn how mass consolidation of carriers and providers (such as hospitals and PBMs) is impacting managed care arrangements
• Identify ways in which carrier intervention in care delivery can increase efficiency and decrease costs, and assess the extent to which such improvements have materialized following recent mergers
• Stay on top of regulatory response to megamergers including CVS Health-Aetna and Cigna-Express Scripts
• Hear what regulators look for in assessing a proposed merger and how to best resist antitrust scrutiny
• Explore the conflicts of interest and litigation challenges that may arise as payors, which are typically involved in disputes with providers, are compelled to take positions that defend the providers that they own
• Understand the reasons for consumer pushback and anticipate future litigation

Payor – Provider Litigation: An Assessment of Frequently Litigated Disputes

• Analyze important decisions rendered in the past year and their implications for the future of managed care
• Identify common coverage disputes, how they are being decided, and what you can do to deter similar actions
• Engage in discussion about disputes specific to the laboratory billing process
• Explore disputes over determination of coverage through Utilization Management and Medical Management Decision Making
• Gain insight into the growing number of disputes over air ambulance billing, which payors are covering in amounts lower than those demanded by providers
• Recognize the role and current limits of regulatory frameworks in addressing dispute resolution
• Assess mixed successes in overpayment recovery by payors as well as trends in provider underpayment litigation

Networking Refreshment Break

Examining Class Action Trends in the Managed Care Space

• Analyze recent class action activity and take away successful defense strategies employed by MCOs
• Explore theories of liability asserted by plaintiffs’ attorneys and their assessment by the courts
• Stay current on the latest class actions over determination of coverage and rates of payment
• Learn about trends in disputes arising from alleged improper coding practices
• Hear about recent moves by provider groups and plaintiff attorneys to challenge payor medical policy provisions relating to individualized benefit determinations that make it difficult to obtain class certification
• Get the latest updates on actions initiated by prostate cancer patients who were denied coverage for proton beam radiation therapy
• Examine reasons for decrease in opioid class action activity, as plaintiffs are instead opting for individual lawsuits

Analyzing Disputes over Fraud and Abuse in Government Healthcare Programs

• Stay current on False Claims Act (FCA) matters as Medicare and Medicaid programs continue to operate through a managed care delivery model at an increasing pace
• Examine recent DOJ criminal and civil actions taken against MCOs and know what AUSAs look for in their investigations
• Navigate the complexities of Medicaid managed care and identify states’ enforcement priorities
• Learn how the nature and frequency of insurer and provider fraud in the public payor market has evolved over the years

Closing Remarks, Conference Adjourns to Day Two

Opening Remarks from the Co-Chairs

Arbitrators’ Insights into Managed Care Disputes

• Identify the kinds of disputes that are most commonly resolved through arbitration and why parties opt for this dispute resolution mechanism
• Examine the rules that govern arbitration that are specific to payor-provider disputes
• Know what makes for a persuasive claim or defense from the perspective of experienced arbitrators
• Learn what pitfalls to avoid in the process in order to maximize your chances of obtaining a favorable decision
• Explore how best to structure an efficient arbitration process

Safeguarding Patient Privacy – Preventing Data Breaches and Resulting Liability

• Monitor class action activity for data privacy breaches, including recent actions against Arizona-based Banner Health, the University of Missouri Health Care, and the University of Chicago Medical Center
• Hear about regulatory scrutiny over information-sharing with non-healthcare parties, as in HHS’ ongoing investigation of Ascension, a major hospital chain and health insurer, for transfer of patient data to Google
• Learn about HHS’ proposed interoperability rule, which would require transfer of health information among parties in healthcare delivery, including between insurers
• Reconcile demands for data sharing with data privacy requirements dictated by the Health Insurance Portability and Accountability Act (HIPAA)
• Be aware of emerging regulations governing data privacy in the American and international context, including how the General Data Protection Regulation (GDPR)’s extraterritorial reach can affect American providers

Networking Refreshment Break

Navigating Coverage Considerations for Behavioral Therapy and Substance Abuse Treatment

• Learn about actions taken under the Mental Health Parity and Addiction Equity Act by the Department of Labor (DOL)’s Employee Benefits Security Administration (EBSA) in the past year
• Examine new arguments made in recent class actions over denied claims for mental health treatment
• Gain insight into disputes between payors and providers over coverage of behavioral therapies for conditions including autism, substance use disorder (SUD), and psychiatric illness
• Hear best practices for resolving reimbursement disputes in which the provider is alleged to have continued treatment beyond what was considered necessary
• Understand how potential changes to the ACA may affect coverage requirements

The Impact of Private Equity Ownership of Providers on Managed Care

• Stay on top of a significant trend of private equity (PE) entities infusing capital into the provider space
• Assess the ramifications of PE ownership for provider-payer relationships and their contracting strategy, as providers resist becoming part of payor networks due to alternative long-term objectives for the acquired facility or cannot join networks due to high rates for services
• Recognize the tension between serving patients and PE’s primary goal of maximizing profitability
• Examine the great volume of actions initiated by PE-owned providers against patients
• Learn how surprise billing legislation may affect the PE phenomenon as potential for profitability decreases
• Be aware of increasing FCA scrutiny towards PE firms in the healthcare space

Networking Lunch

Addressing Pre-emption Challenges in Healthcare Litigation

• Identify the most important pre-emption disputes in the managed care landscape
• Explore case law developments relating to the ACA’s reach in state court disputes, including situations in which essential health benefits mandated by the ACA are superior to those mandated by states
• Learn how changes to Medicare Advantage plans – including concerns relating to prescription drug coverage, caps on services, increase in cost, and mandatory coverage guidelines – are driving debates over state or federal jurisdiction in disputes
• Hear the latest positions taken by the Circuit Courts and the Supreme Court on Medicare Advantage-related cases in which Employee Retirement Income Security Act (ERISA) pre-emption is invoked
• Examine recent disputes over whether federal jurisdiction in certain cases filed in state court is justified on the basis of federal officer removal, with MCOs qualifying as federal officers

The Current Medicare Risk Adjustment Litigation Landscape

• Grasp the evolution of the regulatory and enforcement environment in Medicare Risk Adjustment
• Explore the causes of action and disposition of cases brought by insurers against CMS over alleged underpayment
• Learn about regulatory actions brought against insurers over alleged overpayment
• Hear proactive strategies for Medicare Advantage plans to protect against litigation in light of shifting government positions
• Gain insight into the impact of the audit program for risk adjustment on insurers and how best to manage audit requirements
• Get informed on the status of certain insurers’ challenges to HHS’ risk adjustment formula

Managing Disputes Involving Pharmacy Benefit Managers (PBMs)

• Learn about the recent wave of litigation against PBMs over allegations that they contributed to the opioid epidemic by facilitating access to highly addictive drugs
• Gain insight into antitrust, racketeering, and various state law-based common law claims being made against PBMs for alleged failure to control drug costs
• Hear how PBMs are being implicated in litigation in which they are not directly parties by insurers seeking recovery from pharmacies for drug expenditures (where reimbursement is alleged to have been artificially high)
• Examine trends in litigation by pharmacies against PBMs over lack of coverage for compounded drugs and exclusion from networks

Closing Remarks, Conference Concludes