NON-PAR FACILITY
UNDERPAYMENTS
Kendall Healthcare Group, Ltd. v. Neighborhood Health Partnership, Inc.

Issue(s) in Dispute: Aggregate claims for patients treated in the E.R. and

Jorge M. Abril, P.A.’s Legal Posture: Initial settlement discussions proved

Resolution: Favorable resolution of underpaid claims for Kendall Medical
subsequently admitted to this HCA facility. NHP applied percentage of
Medicare allowable as their reasonable and customary. This firm identified in
excess of two million dollars in underpayments.
fruitless, Jorge M. Abril, P.A. filed suit in the 11th Judicial Circuit Court of
Florida. Case removed to U.S. District Court. Litigation efforts immediately
promoted high level negotiations between NHP and HCA.
Center and all similarly situated HCA facilities.
HMO DENIALS:
CONTRACTED PROVIDER
Mercy Hospital, Inc. v. United Healthcare of Florida, Inc.

Issue(s) in dispute: Long standing (five years) denial and underpayment disputes

Jorge M. Abril, P.A.’s Legal Posture: The firm brought suit for breach of contract

Resolution: Aggressive litigation strategy forced favorable settlement, on behalf of
.
arising under managed care agreement between the parties. Attempts to mediate and
negotiate settlements proved fruitless. Eventually negotiations broke off and suit
filed.
and numerous other theories of recovery including violation of the Federal and
Florida R.I.C.O., Florida civil theft, etc. United failed, in their bid, to impose
arbitration clause.
Mercy Hospital, while preserving the relationship between the parties, resulting in
new contract .
HMO DENIALS:
UNTIMELY CLAIM
SUBMISSION
Cedars Medical Center v. Health Partners of Philadelphia

Issue(s) in dispute: Unilateral failure, on the part of the health plan, to
process claim for unreasonable period of time (eight months from date of
service). Claim denied for untimely submission.

Jorge M. Abril, P.A.’s Legal Posture: Filed legal action claiming bad faith
for unwarranted denial of the claim.

Resolution: Immediate payment for full amount of HMO’s liability.
NON-CONTRACTED
CARRIER: ARBITRARY
APPLICATION OF DRG/PER
DIEM MEDICARE RATES
Palm Springs General Hospital v. United Healthcare of Florida, Inc.

Issue(s) in dispute: HMO routinely underpaid facility by applying lowest of

Jorge M. Abril, P.A.’s Legal Posture: The firm requested an advisory

Resolution: Upon receipt of favorable advisory opinion, managed care plan
DRG payment rate or Non-DRG Medicare per diem rate. Clear violation of
federal Medicare reimbursement statutes
opinion substantiating its position.
conducted audit and adjusted for proper reimbursement.
HOSPITAL LIEN
IMPAIRMENT
HealthSouth Doctors’ Hospital v. D.A.C & L.C.

Issue(s) in dispute: Personal injury attorney refused to recognize hospital

Jorge M. Abril, P.A.’s Legal Posture: The firm filed suit against the patient

Resolution: The firm obtained significant partial payment from the State of
lien on the basis that the injuries sustained were a result of a violent crime.
and guarantor seeking enforcement of hospital’s lien.
Florida’s Crime Victims Compensation Fund and then proceeded to secure
further remuneration from award of damages in tort action against person(s)
responsible for the injuries.
RETROACTIVE TERMINATION
OF COVERAGE FOR LATE
PAYMENT OF PREMIUMS
Pan American Hospital, Inc. v. Y.S.A. v. United Healthcare of Florida

Issue(s) in dispute: Despite accepting receipt of late payments, HMO

Jorge M. Abril, P.A.’s Legal Posture: The firm filed suit directly against the

Resolution: The case was tried before the Court. Award of damages in favor
rescinded member’s policy and denied claims related to this admission.
patient, whom subsequently brought third party action against the HMO on
estoppel theory.
of provider and member. United Healthcare ordered to pay its full
responsibility to the facility, plus interest and attorneys’ fees.
CATASTROPHIC CLAIM
CARVE-OUTS
Mount Sinai Medical Center, Inc. v. Vista Health Plans, Inc.,
as successor to Foundation Health

Issue(s) in dispute: Hospital identified a disturbing pattern of
underpayments by the health plan on high dollar catastrophic claims.

Jorge M. Abril, P.A.’s Legal Posture: The firm brought suit in circuit court
under breach of contract and other legal remedies.

Resolution: The HMO has asserted an aggressive defense to the issues raised
in the pleadings. Both sides are currently exploring settlement options. To
date, no resolution has been obtained and the case is proceeding to trial in late
2006.
UNDERPAYMENTS/DENIALS
NON-CONTRACTED
ANCILLARY PROVIDER
West Dade Anesthesia Associates v. Total Health Choice, Inc.

Issue(s) in dispute: HMO unilaterally underpaid and denied dozens of

Jorge M. Abril, P.A.’s Legal Posture: A multi-count complaint was filed, in

Resolution: After several months of contentious litigation, the parties came
claims by applying an incorrect reimbursement code, in direct violation of the
parties’ Provider Service Agreement.
Miami-Dade county Circuit Court, under numerous theories of recovery,
including breach of contract.
together to negotiate global settlement, including the execution of a revised
contract with increased provider payment rates. The new contract served as
an incentive for an amicable settlement of all issues.
CONTRACT INTERPRETATION
DISPUTE
American Medical Response (AMR) v. CarePlus Health Plans, Inc.

Issue(s) in dispute: The health plan issued a sharp increase in provider

Jorge M. Abril, P.A.’s Legal Posture: In order to uphold the long-standing

Resolution: The parties executed a global settlement and executed a revised
payments due to its inability to control utilization after parties moved to fee
for service compensation. Health plan unilaterally withheld significant
payments to the provider.
relationship between the parties, the firm refrained from filing suit and,
instead, engaged in high level negotiations with health plan executives.
contract premised on the health plan exercising greater control over
utilization, while still compensating the provider at competitive and profitable
rates.