Litigation and Alternative Dispute Resolution

Gjerset & Lorenz’s litigation practice combines health care expertise with experienced litigators. Specifically, Gjerset & Lorenz attorneys are renowned for achieving outstanding results for clients in payment disputes with insurers and state payors. A large part of our litigation practice involves complex contract disputes relating to provider claims for reimbursement and “issue disputes” that shape reimbursement principles. Since 2002 Gjerset & Lorenz has won and collected in excess of $300 million for our clients and over the same time period has helped clients use reimbursement disputes as leverage to lock-in long term rate increases in both the public and private sectors.

Our attorneys have extensive experience dealing with the ancillary issues that arise in payment and contract disputes including state insurance code regulations, bad faith, tortious interference and fraud. We have advised clients on a wide range of issues relating to appeals of Texas Medicaid denials for timely filing of claims, State Medicaid administrators’ failure to pay outlier payments, and workers’ compensation carriers’ refusal to pay stop-loss and high cost pass through items pursuant to state regulations.

We recognize that collection of unpaid or underpaid claims is most profitable if litigation can be avoided and a long-term business solution can be obtained that benefits both the provider and the payor. We work with our clients to determine the most economical and expeditious course of action to meet their needs including creative contracting solutions to lock down long-term rate increases and other contractual increases in lieu of retrospective payments for previously written-off debts. We place a premium on pre-litigation efforts and alternative dispute resolution, and have used that approach to successfully resolve many disputes before litigation commenced.

Results in recent representative cases include:

• $200 million in additional Medicaid reimbursement collected for over 50 hospitals in California, Texas, Pennsylvania and Florida based on administrative appeals of Medicaid Disproportionate Share Hospital funding decisions.
• $16 million global resolution of a dispute over the contractual provisions governing high cost pass through reimbursement for 14 hospitals, which included $4 million in cash settlement and $12 million in prospective rate adjustments.
• $10 million collected for 9 hospitals upon completion of the claimant’s case in chief against an insurer who denied hundreds of claims arguing that the hospitals were required to bundle items including stop loss reimbursement.
• $5.5 million collected judgment against an insurer that underpaid hundreds of claims by arguing the contract required daily level of care authorizations, refusing to comply with stop-loss provisions and down-coding.
• $4.5 million collected pursuant to an arbitration award against a Medicare+Choice plan for its denial of Medicare non-allowable charges.
• $4.3 million collected as full recoupment of underpaid claims from a national insurer that argued its downstream risk-bearing IPAs were responsible for the claims.
• $3.8 million judgment plus interest and penalties obtained against an IPA that removed line item charges to pay stop-loss claims.
• $3.1 million recovery against a state Medicaid program for inappropriate timely filing denials.
• $1.8 million collected in a successful counterclaim for underpayment against a managed care company that had sued our client for breach of contract and violation of the duty of good faith and fair dealing alleging $2.5 million in damages because the hospital had increased its charges.
• $1.5 million collected for hundreds of accounts a managed care company denied based on arguments that Medicare and Medicare+Choice claims were preempted by Federal law.
• $1.3 million collected from a managed care company that had attempted to pay emergency medical triage rates rather than room rates for certain patients.
• $1.25 million recovery against a state Medicaid fiscal intermediary for improper denials.
• $600,000 collected from a managed care company that had failed to pay a single claim, arguing that the member was not eligible for the services he had received.
• $550,000 collected for a managed care company’s denial of stop-loss claims.
• $500,000 recovery against state Medicaid program for underpayment of outpatient claims based on an erroneous interim rate calculation.