Managed Care

Sedgwick’s extensive insurance background uniquely positions the firm’s managed care attorneys in investigating, analyzing, strategizing and litigating healthcare disputes. Drawing on the experience of attorneys from our healthcare and insurance practices, we have created a dedicated managed care defense team. Our attorneys have a solid understanding of managed care programs and are well-versed in the legal liability issues associated with these programs. 

Sedgwick’s Managed Care practice is part of the firm’s Insurance Division, one of the largest international teams of trial attorneys and business advisors dedicated to the institutional concerns and success of the insurance industry. Our clients cover the spectrum of the insurance industry and include some of the country’s largest managed care insurers.

Managed Care Litigation

Sedgwick has long held a reputation as one of the top trial law firms in the nation. Our lawyers have acted as regional counsel for major managed care providers in the United States and have defended multiple national class actions. We have successfully defended liability issues involving utilization review, benefits and claims determinations, ERISA, credentialing, peer review, privacy claims, breach of contract and alleged unlawful or fraudulent business practices in managed care cases. We also advise our managed care clients on various aspects of their operations, including labor and employment policies and compliance with federal regulations.

Employee Benefits Disputes

Sedgwick applies our expertise as a trial firm to representation of individuals and employee benefit plans in ERISA fiduciary litigation. Our attorneys represent employee benefit plans, plan fiduciaries and third party administrators and provide counseling, trial expertise and representation in administrative hearings. We have significant experience defending managed care organizations and their insurers against claims made by benefit recipients. We have defended hundreds of benefit disputes and claims relating to ERISA, HIPAA and other federal legislation. Our lawyers deal with state attorneys general offices and state departments of insurance. 

We also represent employee benefit plans that are not governed by ERISA in state and federal courts. Our ability to explain complex concepts in understandable terms and our extensive experience in handling employee benefit cases enable us to obtain successful summary resolution of most of the actions we defend. When summary resolution is not available, our trial expertise enables us to efficiently and effectively present both the technical and non-technical portions of claims.

HIPAA Compliance

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) initially impacted the healthcare industry by mandating the “portability” of health insurance for employees changing jobs, prohibiting discrimination based on health and easing pre-existing condition restrictions imposed by health plans. HIPAA’s requirements expanded in 2002 with the promulgation of a comprehensive set of regulations—referred to generally as the Privacy Rule—addressing the confidentiality of “protected health information” created or maintained by managed care plans, health plan clearinghouses, or healthcare providers that transmit health information in electronic form.

We partner with our clients to provide cost-effective HIPAA compliance. Our team of experienced attorneys provides comprehensive risk assessment and gap analysis, HIPAA training as required by the Privacy Rule, and work plans tailored to the needs of hospitals, physicians, health plans and ERISA benefits plans. We provide training and instruction materials to executive and administrative staffs leading to certification in the required compliance plan. Business associate agreements, notices of privacy procedures and other necessary forms are also provided by Sedgwick’s HIPAA attorneys. We coordinate overall compliance activities with security and information technology consultants.

Fraud and Abuse

Fraud and abuse investigations in the healthcare arena often involve both civil and criminal statutes. The firm’s experience in medical matters is key to evaluating and responding to government scrutiny.

We also provide clients with tools to manage the increasing risk of fraud and abuse investigations. Our attorneys conduct preventive audits of existing compliance programs and plan for internal investigations. Often future problems can be prevented at this level, at a considerable savings in both time and cost. Additionally, we constantly monitor changes in legislation and in court decisions to alert clients to new developments.

Insurance and Coverage

Sedgwick attorneys are experienced in managed care insurance coverage analysis, as well as in the substantive legal issues at play in the underlying claim asserted against the managed care provider. The firm’s extensive insurance background uniquely positions us to investigate, analyze, strategize and litigate managed care disputes.

For more than 20 years, Sedgwick has represented the interests of excess insurers within the context of a healthcare liability claims program. Through our management of more than 25,000 claims across the United States, we can efficiently and effectively identify the most advantageous strategy for guiding claims to resolution. Moreover, we have established relationships with medical experts throughout the country to better coordinate the defense of the claims we handle. Our attorneys also collaborate with many clients to draft insurance claims guidelines and policy language to underwrite the new world of managed care, which provides a major advantage when disputes arise. 

Technical Support

An extensive medical library supports the attorneys at Sedgwick. For rapid and efficient research, our attorneys have desktop access to Medline and the National Library of Medicine.  The firm periodically retains physicians, medical consultants and other healthcare practitioners to interpret and clarify issues from a medical point of view. Through these professional relationships, our attorneys become familiar with state-of-the-art medical techniques used for diagnosis and treatment. The experience our attorneys have in preparing and trying managed care cases, coupled with their medical backgrounds and ready access to medical information, allows for expeditious handling of complex cases.

Seminars and Publications

Sedgwick attorneys provide in-service seminars to client hospitals on subjects such as:

  • Risk management aspects of charting
  • “Bloodless” surgery
  • Confidentiality of psychiatric clinical records
  • Involuntary outpatient commitment
  • Advance directives
  • National Practitioner Data Bank
  • Confidentiality, security and discovery issues concerning electronic communications between physicians and between physicians and patients
  • Informed consent

Our attorneys strive to keep our clients informed about new healthcare issues and periodically prepare newsletters and case law updates for our clients. Sedgwick attorneys frequently publish articles in leading healthcare and legal publications on emerging healthcare issues.  We write, edit and publish the Healthcare Law Newsletter, a quarterly update for our clients that features articles by our attorneys on significant developments affecting the healthcare industry.

Our books and treatises include the “Healthcare Liability Deskbook” published by The West Group, and “State Law Challenges in Managed Care,” which is published as part of the treatise, “Managed Care Litigation,” a 2005 desk reference for managed care attorneys and executives published by BNA Books in conjunction with the ABA Health Law Section.  Sedgwick also published the “Handbook for Management and Resolution of Hospital Malpractice Claims,” which was created to assist risk management personnel in resolving claims brought against their institutions.