AHLA Health Plan Disputes and Litigation Practice Guide (AHLA Members)
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Be prepared for an increase in health plan-related litigation.
The passage of the Affordable Care Act has led to numerous changes to the delivery of health care, including marketplaces to purchase insurance to cover health care expenses. As more people become insured, their health plan decisions become even more important to them and to the health plan industry in general. While health plans are moving to take advantage of the changes, the likelihood for an increase in lawsuits involving health plans, their clients, and others involved with the delivery of health care becomes greater.
Expert guidance for informing your counsel.
Experienced practitioners Joseph Scott Schoeffel and Julie A. Simer provide thorough treatment of those areas likely to give rise to disputes. The authors answer the important questions critical to an understanding of this area:
- Who is the client?
- Is the dispute a managed care issue?
- Is the plan covered by ERISA? What are the implications?
- What are the causes of action against a health plan?
- What causes of action may be asserted by the health plan?
- What are the common reasons for denial of coverage?
- What defenses are available against an ERISA claim?
- When may the arbitration be required?
Comprehensive coverage of the most frequently litigated areas.
The authors of this publication have included the litigated topics including:
- Denial of benefits
- The Employee Retirement Income Security Act of 1974 (ERISA) and whether it preempts the question in contention
- The failure of providers to demand co-payments from their patient
- The numerous defenses that may be available to defeat ERISA-based claims
- Context for your case
- Important background is included to provide context for any case that arises.
- Types of managed care organizations, including Health Maintenance Organizations, Preferred Provide Organizations, and others
- The nature of employer sponsored health plans and the impact on those by ERISA
- Questions that must be considered prior to filing a lawsuit against the plan—such as venue, the limited remedies available under the law, and the distinction between insurance governed by the states as opposed to ERISA
- Causes of action that arise under ERISA, as well as the defenses that may be asserted to defeat a claim
The publication also includes relevant documents, case summaries and a litigation decision tree.
Published June, 2015.
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Table of Contents
1 The Role of Health Plans in the United States
2 Who is the Client?
3 Is this a Managed Care Issue?
4 Is the Health Plan Sponsored by an Employer?
5 What are Some of the Relevant Documents?
6 What other Causes of Actions may be Filed Against a Health Plan?
7 What are Common Reasons for Denial of Benefits?
8 What Defenses are Available to Defeat an ERISA Claim?
9 Was Provider In-Network?
10 Does Dispute Involve a Medicare or Medicaid Health Plan?
11 What Causes of Action may Health Plan Assert?
12 When may Arbitration be Required?
13 Has Market Competition been Affected?
14 Is Member's Health Information at Risk?
15 Does Dispute Implicate Affordable Care Act?
Appendix A Commonly Used Health Care Terms
Appendix B Case Summaries
Appendix C Managed Care Litigation Decision Tree