RECENT MANAGED CARE CASES

Following is a brief description of recent managed care litigation undertaken by the firm.

Kendall Regional Radiology & Imaging v. Neighborhood Health Partnership. Under Florida and federal law, KRRI was under an obligation to treat the patients who presented to the hospital in emergent conditions regardless of insurance coverage. NHP placed language in the agreements with its members that set forth the rate at which non-contracted providers would be paid. In this case, the member agreements at issue dictated that KRRI should be paid at the reasonable and customary rate, but no explanation was provided as to how that rate should be calculated. This firm instituted a lawsuit in Federal Court under ERISA (Employee Retirement Income and Security Act) claiming benefits due under a commercial insurance plan. NHP paid a certain amount for the services provided claiming that said amount was reasonable and customary. KRRI contended that the payment was willfully inadequate and not reasonable and customary for the services provided. NHP filed a Motion for Summary Judgment claiming that administrative remedies under ERISA had not been exhausted prior to the filing of the lawsuit. This firm responded that administrative remedies had, in fact, been exhausted and that KRRI should not be precluded from maintaining its action in Federal Court. The firm relied on a number of specific cases which stood for the proposition that ERISA itself contained no requirement that a particular plan’s specific administrative review procedures must be followed before a Plaintiff can sue in Federal Court. Florida Health Sciences Center, Inc. v. Humana Medical Plan, Inc., 190 F.Supp. 2d 1297 (M.D. Fla. 2001). The Court agreed with our argument and denied the Defendant’s Motion for Summary Judgment, at which point the parties were ordered to begin trial Monday of the subsequent trial period. In addition, the parties were ordered to attend a mediation settlement conference, at which the parties resolved all pending issues. 

Jackson Memorial Hospital v. Total Health Choice. In a case with similar implications to the foregoing, the firm was retained to represent Jackson Memorial Hospital in two separate actions for underpaid claims by a non-contracted provider. The cases languished in discovery for over a year as Total Health Choice, through its attorneys, sought the production of a burdensome number of documents from the hospital. The cases were referred to a General Magistrate who was able to control the discovery and narrow down the issues sufficient to bring the case to trial. On the eve of trial, the parties executed a Confidential Settlement Agreement which estab-lished a reasonable compensation for-mula and allowed the parties to go forward with a new contractual relationship.