Out-of-Network Defense

Protecting Patients and Health Plans Across the U.S.

Koehler Fitzgerald LLC provides highly specialized legal services, representation and advocacy for self-insured health plans, their members and sponsors, third-party administrators, as well as medical benefit plans offering reference-based pricing (RBP).

The firm’s services encompass defense of out-of-network claims, claim repricing and scrubbing, and the national defense of patients confronted with balance billing claims. Additionally, the firm can represent plans nationally in the recovery of claim overpayments.

Koehler Fitzgerald’s services cover all stages of collection activity, from advocacy to provider billing to jury trial and appeal.

Koehler Fitzgerald’s lawyers are familiar with state and federal consumer credit laws, such as the Fair Debt Collection Practices Act and state balance billing acts, as those laws relate to medical billing practices which are designed to protect consumers and patients against out-of-network and unreasonable billings by health care and medical providers and unfair debt collection practices employed by creditors and collection agencies. The firm’s highly rated trial and appellate lawyers partner with nationally recognized experts and affiliated local counsel in jurisdictions throughout the United States in mounting a coordinated defense of out-of-network and balance billing claims.

Koehler Fitzgerald's multilingual out-of-network defense services are supported by a proprietary and customized database which is used to track and support group calendaring, task management, contact management, conflicts checking, integrated document assembly and customizable reports showing the up-to-date status of claim or litigation activity.

Through the use of its database, Koehler Fitzgerald is able to offer customizable weekly, monthly and annual reports to its partners. Examples of the type of data that can be included are claim status, disputed amount, original billed amount, settlement amounts, claims by provider, claims by plan, and percentage of savings. Because the database is fully relational, any category of information may be tracked and reported. The reports can be specific to one plan, multiple plans or provide a general overview.

The engagements are led by three partners: James Koehler, Timothy Fitzgerald and Christine Cooper. Steve Mueller, Director of IT, oversees the database and Jasmine May, VP of Administration, supports the defense process. Contact center staff members are tasked with handling daily calls and speaking with each patient at least monthly. Bankruptcy lawyer, Robert Barr, supports as needed. The firm also employs a full-time data entry staff.

A principal focus of the firm, the lawyers in this practice group have a record of savings of up to 70% of billed charges for more than 115 health plans nationwide. The firm offers alternative fee arrangements which permit plans to forecast expenses with certainty.