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healthcare disputes 

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KGKristina Giyaur
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HEALTHCARE LITIGATION AND DISPUTE RESOLUTION

Our healthcare litigators are at the forefront of the rapid and profound changes affecting the healthcare industry.  We serve our healthcare clients by efficiently resolving civil disputes through pre-litigation planning, negotiation, mediation, trial and appellate litigation, and alternative dispute resolution methods.  We have substantial experience resolving disputes involving a wide range of healthcare providers, including doctors, hospitals and health systems, long-term care facilities, home health agencies, ancillary service providers, laboratories, pharmacies, free-standing ancillary and surgery facilities, information technology and other medical suppliers, healthcare consultants, as well as pharmaceutical and medical device companies.

The key to our success is

  • Our deep knowledge and understanding of the industry.
  • Our cost-consious approach that is aimed at preserving our clients' financial well-being.
  • Our sharp focus on the issues affecting the industry that informs our dispute-resolution strategies and translates into optimal solutions for our clients.
  • Our personal attention to each individual client regardless of the size and complexity of the issue

We offer litigation expertise in the following areas of concern to our healthcare clients:

PROFESSIONAL ARRANGEMENTS

We represent healthcare providers and entities in disputes regarding staff privileges, misconduct, credentialing, employment, contractual arrangements, compensation and problems arising from contractor relationships and joint ventures. These matters typically involve complex ongoing relationships requiring creative solutions that are possible by knowing the industry from the inside. Our health care litigation team is well-versed in handling claims of discrimination and wrongful termination.


REIMBURSEMENTS AND MANAGED CARE

Healthcare providers, including medical and pharmacy providers who were denied reimbursement by federal healthcare programs or private payers turn to us to assist them in enforcing their rights. Managed care and PBM disputes often involve non-monetary challenges to medical necessity, site of service, and other complex factors involved in payment for healthcare services, making this type of litigation much more than a contract or collection matter.  Challenges to pharmacy payment denials and recoupment demands are sometimes extremely complex and involve highly technical knowledge of the industry's practices and inner workings. We represent clients pursuing these issues not only in courts, arbitration and mediation proceedings, but in administrative hearings, in carrier or intermediary fair hearings, and through managed care grievance processes.

PARTNERSHIP AND SHAREHOLDER DISPUTES

Partnership and shareholder disputes are common in the healthcare industry.  An unavoidable aspect of doing business is that amicable business relationships among partners, corporate officers and directors, employees and employers, competing businesses, etc. occasionally sour. Whether as a result of retirement, death, disability, or unresolved professional or personal disputes, the breakup of an established physician practice or the departure of one or more of the physicians in the practice can be a trying ordeal for everyone concerned. We understand the financial, ethical, professional, and emotional issues that come to play during partnership disputes. Of course, even when a practice has in place the necessary documents, not every issue will be covered, and often the agreements reached by the parties may have become stale with time. We try to negotiate pre-litigation resolution of most disputes, but, when negotiations fail, we represent and guide healthcare providers through the difficulties and challenges of litigation or arbitration.

CIVIL RICO

Healthcare providers and suppliers are increasingly becoming targets of Civil RICO lawsuits brought by insurance companies and other entities with large litigation budgets.  We are well-versed in various aspects of defending health care providers in such cases, and can effectively manage and defend health care providers against Civil RICO allegations in the most complicated matters.

JUDICIAL REVIEW OF ADMINISTRATIVE PROCEEDINGS

We assist physicians who are dissatisfied with the outcomes of OPMC hearings to appeal the finding administratively or judicially. Unique to the OPMC disciplinary process, both the licensee and the state of New York can appeal the outcome of the underlying hearing process to the Administrative Review Board (“ARB”). The ARB hears appeals from the Department of Health or physicians and issues a final order. A proceeding before the board is the final administrative remedy available in the disciplinary process. After administrative remedies have been exhausted, either the hearing panel’s decision or the ARB’s determination can be appealed through an Article 78 proceeding in the Appellate Division, Third Department, State of New York.  We represent physicians in connection with judicial review of the administrative decisions to determine if they were manifestly wrong or the agency had abused its discretion.

OTHER MATTERS

Other litigation and dispute resolution matters in which we represent healthcare providers include:
  • Disputes regarding claims adjudication policies and practices and claims payment
  • Disputes regarding pharmacy submission requirements, coverage determination, and claims payment
  • Disputes relating to Medicare Advantage and Medicare Part D prescription drug benefit plans, including compliance actions
  • Disputes between beneficiaries and providers related to coverage determinations
  • Disputes relating to pharmaceutical drug pricing and drug promotion
  • Disputes relating to claims payment administration and repricing of claims, in the contexts of commercial health plans, rental networks, and workers compensation
  • Disputes with regulatory authorities regarding compliance with statutory and administrative requirements
  • Misappropriation of trade secrets and unfair competition

WHAT WE OFFER

  • Litigating healthcare disputes in federal and state courts in New York and New Jersey from commencement through trial
  • Deep understanding of healthcare-related business issues that help us to choose best strategies and arguments
  • Unparalleled access to a wide array of experts in various aspects of healthcare business
  • Litigation avoidance counseling and internal auditing

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