Managed Care Disputes and Litigation

Brenna Jenny (Deputy Assistant Attorney General, Commercial Litigation Branch) and Beth Kelley (CMS Chief Legal Officer) will examine the evolving enforcement landscape surrounding managed care, drawing on recent cases, investigative and auditing trends, and policy priorities. They will explore how CMS regulators and DOJ Civil Fraud are approaching issues such as prior authorization practices, network adequacy, risk adjustment, marketing, quality of care, and the use of data analytics to detect fraud and systemic noncompliance.

The U.S. managed care industry is navigating a volatile political environment that is reshaping regulation and increasing litigation risk. This will examine the latest political and policy developments, exploring how shifts at both federal and state levels are affecting health plans.

Participants will gain insights into emerging legal and regulatory challenges and learn strategies to proactively manage risk in this rapidly evolving landscape.

• Identifying emerging litigation and regulatory risks
• Understanding implications of political changes on MCOs
• Implementing proactive strategies for compliance

Artificial Intelligence (AI) is transforming how managed care organizations operate. From prior authorization and population health management to risk adjustment, MCOs are well positioned to capitalize on the deployment of innovative AI tools. However, implementing these technologies also introduces new regulatory and legal challenges.

This session will equip MCOs with a clear understanding of the evolving state and federal AI regulatory landscape, as well as strategies to manage emerging litigation and enforcement risks. Panelists will share practical guidance on:

• Establishing an effective AI governance program that meets state Department of Insurance (DOI) requirements and aligns with evolving federal expectations
• Mitigating risks associated with class action litigation challenging the use of AI
• Strengthening defenses against AI-related enforcement actions through active delegation oversight and thoughtful utilization management practices
• Describing Medicare’s WISeR pilot and anticipating its influence on fraud, waste, and abuse detection in managed care

Recent court rulings have paused federal Independent Dispute Resolution (IDR) under the No Surprises Act, creating uncertainty for payors and providers. This session will examine the Texas Medical Association (TMA) III decision, its impact on QPA calculations and arbitration timelines, and provide practical strategies to navigate disputes, manage compliance risk, and protect reimbursements in a shifting regulatory landscape.

• Understanding the impact of TMA III on QPA calculations and IDR processes
• Managing financial, operational, and compliance risks arising from IDR developments
• Navigating disputes with practical strategies to protect reimbursements and ensure compliance

In addition to its role in the IDR process under the No Surprises Act, arbitration plays a part in countless MCO disputes. Back by popular demand, this interactive panel will answer all the questions you’ve been afraid to ask!

During the session, the panel will address “live” questions, providing participants with actionable strategies to navigate arbitration efficiently and reduce risk.

Topics of discussion will include:

• Understanding how the arbitration selection process works
• What are the pros and cons to arbitration with just one arbitrator versus an arbitration panel?
• Determining which disputes belong in arbitration and which belong in court
• Providing guidance around the true finality of an arbitration decision

The 340B Drug Pricing Program allows eligible healthcare providers to purchase medications at discounted prices to support care for underserved populations. While the program offers significant benefits, it also introduces compliance and operational risks that can impact managed care plans. This session will examine recent enforcement actions, regulatory scrutiny, and emerging challenges associated with 340B, and provide strategies for payers to manage risk, ensure accurate reimbursements, and maintain compliance.

• Understanding 340B program rules, eligibility, and compliance requirements for covered entities
• Assessing 340B’s effects on plan reimbursements, formulary decisions, and operational processes
• Developing best practices to mitigate litigation risk associated with regulatory non-compliance
  • Billing errors, duplicate discounts

The managed care industry is under pressure to move from traditional fee-for-service models toward value-based care (VBC) arrangements. Payers and providers face challenges in aligning financial incentives, coordinating care, and measuring outcomes, all while maintaining compliance and controlling costs. This session addresses the operational, legal, and financial risks associated with VBC contracts, and provides strategies to successfully navigate this shift in the healthcare landscape.

• Understanding why value-based care is a top priority and emerging risk in managed care
• Identifying operational, financial, and compliance challenges in outcomes-based contracts
• Implementing practical strategies for contracting, risk-sharing, and dispute resolution