Case Studies

Epstein Becker Green Helps Health Insurance Carrier Obtain Reversal of Premium Rate Disapprovals

On August 6, 2010, Epstein Becker Green helped its client Fallon Community Health Plan, Inc. ("FCHP") obtain the reversal of the Massachusetts Division of Insurance ("Division") disapproval of certain of FCHP's premium rate increases. The Division had previously disapproved all premium rate increases filed by FCHP and other health insurance carriers for small business and individual customers that exceeded 7.7 percent — which was 150 percent of the New England Medical CPI for 2009. FCHP and the other affected health insurance carriers filed administrative appeals of the Division's disapprovals of their premium rates. The Massachusetts Attorney General's Office intervened in the administrative hearings on behalf of consumers' interests. Epstein Becker Green, which along with local counsel represented FCHP, presented documentation and testimony justifying FCHP's rates from actuaries, provider contracting executives, and other witnesses.

After examining the evidence, the presiding hearing officers reversed the Division's disapprovals of FCHP's premium rates, finding, among other factors, that FCHP had made reasonable efforts to keep costs down through provider contracting, and utilization control and cost containment programs. The presiding hearing officers also adopted EBG's arguments that the Division's reliance on Medical CPI to reject premium rates was flawed. As a result of the reversals, FCHP was able to implement its filed rate increases through the end of 2010.

Epstein Becker Green and its attorneys Jesse M. Caplan, George B. Breen, and Robert E. Wanerman of the Washington, D.C., office served as co-counsel, along with local counsel Bowditch & Dewey, in representing FCHP.

Epstein Becker Green Successfully Negotiates Medicaid Managed Care Program Contract for Client Based in Puerto Rico

In October 2011, Epstein Becker Green represented Triple-S Management Corp. ("Triple-S") in the negotiation of a contract with the Puerto Rico Health Administration ("ASES") to administer the Medicaid managed care ("Mi Salud") program in five out of nine regions in Puerto Rico. Failure to reach an agreement on the terms of the contract would have left over 800,000 people without coverage, beginning November 1, 2011. Triple-S agreed to step in and assume these regions of the Mi Salud program after contractual issues between ASES and the current MCO contractor could not be resolved.

The Epstein Becker Green team representing Triple-S included Philip D. Mitchell of the Newark office and Jane L. Kuesel and Joseph J. Kempf, Jr., of the New York office.

Epstein Becker Green Successfully Represents Sibley Memorial Hospital in Acquisition of Certificate of Need for Three Proton Therapy Stations

On May 31, 2013, and on April 30, 2014, the State Health Planning and Development Agency for the District of Columbia approved two adult and one pediatric proton stations, respectively. Epstein Becker Green represented Sibley in a hotly contested regulatory process.

The Epstein Becker Green team was led by Clifford E. Barnes and included Jonah Retzinger and Marshall E. Jackson.

Epstein Becker Green Successfully Represents a Home Health Care Agency in the Termination of a Medicaid Payment Suspension

On May 21, 2014, Epstein Becker Green, on behalf of a home health care agency client, successfully negotiated a settlement agreement with the D.C. Department of Health Care Finance (“DHCF”), ending the suspension of Medicaid payments due to the client.

The client participates in the District of Columbia’s Medicaid program and provides personal care aide services to residents of the District. In March 2014, the DHCF issued a Notice of Temporary Suspension under 42 C.F.R. 455.23, indicating that, based on credible allegations of fraud, the agency would immediately suspend payments due to the client for providing personal care aide services.

The client, with the assistance of Epstein Becker Green, settled the matter within two months of the Notice of Suspension.

The Epstein Becker Green team was led by Clifford E. Barnes and included Jonah D. Retzinger.