Managed Care Litigation & Compliance



Wilson Elser enjoys extensive experience and a well-earned reputation for success in representing managed health care organizations and related entities on a wide range of litigation, regulatory and risk management matters. Our clients include large national HMOs and PPOs along with pharmacy benefit managers, regional health plans, and specialized plans for behavioral health, dental and vision. We also represent independent practice associations and third-party administrators.

Our managed care attorneys, several of whom draw on industry experience, are strategically located throughout the United States. We maintain offices in or near jurisdictions traditionally known as “hotbeds” of related litigation and enforcement actions, including those in California, New York, Texas, Illinois and Florida.

With respect to provider litigation, we handle cases in the courts and through binding arbitration that range from routine contract and reimbursement disputes to large, complex commercial controversies, frequently involving millions of dollars. We also assist clients with member/enrollee disputes and have extensive experience handling cases preempted by ERISA. Cases not governed by ERISA include high-stakes matters often involving alleged wrongful denials of benefits for catastrophic illnesses and injuries; asserting numerous state law theories of liability such as bad faith, unlawful business practices wrongful death; and seeking tort and punitive damages and injunctive relief. We also handle cases involving alleged RICO claims and other violations of federal and state statutes.

Regulatory compliance and enforcement matters have increasingly, and necessarily, become a focus of our Managed Care practice. We assist clients with related actions brought by local, state and federal agencies and prosecutors. These include state-level departments of insurance and/or managed health care, attorneys general and medical boards; the Centers for Medicare & Medicaid Service (CMS); the Office of Inspector General (HHS-OIG); and the Department of Justice (DOJ). In addition, we provide practical counsel to clients on the preparation and maintenance of compliance policies and procedures relative to applicable state and federal statutes.

The health coverage market continues to expand in the United States as higher-risk individuals are able to obtain coverage regardless of health status. Also, the potential influx of insured patients into the managed care system as a result of the Affordable Care Act will undoubtedly result in more litigation and an array of new issues, including medical-loss ratios, premium rate increase reviews, provider nondiscrimination and insurers retreating from health insurance exchanges.

Wilson Elser has long been considered a “go-to” firm in areas related to insurance and health care. This designation applies equally to our accomplished managed care attorneys who have deep roots in the industry and an enviable record of advancing our clients’ related litigation, regulatory and risk management objectives.