Healthcare Law
When a carrier sues your practice, the complaint is designed to frighten you. That design is the first thing to understand.
The firm defends healthcare providers — physicians, chiropractors, pharmacies, and medical practices — in litigation brought by insurance carriers, and in audits and investigations. It also handles the transactional and structural work that determines how well a practice holds up when it is attacked.
Litigation defense
Insurer fraud and civil RICO lawsuits
Carriers file fraud and civil RICO suits against providers in volume, particularly in the no-fault space. The business logic is straightforward: a RICO claim raises the potential damages, generates leverage, and lets the carrier bundle years of paid claims into one action while simultaneously justifying withheld reimbursements.
Common carrier theories:
- Alleged improper ownership or control of the practice by non-physicians — the Mallela theory in New York's no-fault context
- Alleged medically unnecessary treatment, or predetermined treatment protocols
- Alleged improper relationships with management companies, laboratories, or referral sources
- Billing and coding allegations recast as mail fraud, the predicate for civil RICO
An accusation is not a finding. These complaints are pleadings, built for maximum pressure, and they are defensible.
A provider's guide to insurer RICO lawsuits →
Declaratory judgment actions
Carriers bring DJ actions to establish that they owe nothing — often on the basis of an alleged staged accident, an alleged failure to appear for an examination under oath, or an alleged structural defect in the practice. These are defended on the facts and on the carrier's own compliance with the no-fault regulations.
No-fault litigation and arbitration
Reimbursement disputes, denials, and the arbitration practice that surrounds them.
Provider audits and investigations
CMS, Medicaid, and Medicare audits, and the responses that determine whether an audit becomes something worse.
Structure, transactions, and compliance
- MSO and MSA agreements — drafting, review, and diligence
- Corporate practice of medicine compliance — who may own and control a practice in New York
- Pharmacy and provider contracts
- Practice formation and structuring
- Healthcare compliance — HIPAA, the Stark Law, the Anti-Kickback Statute, and the False Claims Act
The structural work and the litigation work are the same subject seen from two ends. A carrier attacking a practice's ownership structure will read the MSO agreement. What that document says, and what the corporate records show, is frequently the case.
How the firm defends these cases
The defense runs on two tracks at once: the litigation itself, and protecting the practice's cash flow and operations while it pends. A provider who wins the case three years from now but cannot make payroll next month has not been well served.
The pleading. Fraud and RICO must be pled with particularity. Carrier complaints often paper over the who, what, and when with statistical generalities. Motions to dismiss test whether there is a case at all, and can narrow years of claims out of the suit.
The enterprise and the pattern. Civil RICO requires a distinct enterprise and a pattern of racketeering activity — not merely a billing dispute wearing a frightening label. Courts dismiss RICO claims that are contract disputes in costume.
The structural theory. Where the carrier attacks ownership and control, the defense lives in the actual documents and conduct: who made clinical decisions, how the MSO agreement allocated functions, what the corporate records show.
The billing proof. Carriers rely on data patterns. Patients are treated one at a time. Peer review, medical necessity evidence, and claim-by-claim proof push back against statistics.
If your practice has just been sued: the first two weeks
- Preserve everything — clinical, billing, corporate, and communications.
- Do not call the carrier's counsel or its SIU to "clear things up." That conversation becomes an exhibit.
- Notify your brokers about potential coverage for defense costs.
- Map every collateral front — pending arbitrations, audits, other carriers. The lawsuit is rarely the only thing happening.
- Get counsel who understands both federal RICO practice and healthcare structure. The defense sits at that intersection.
Frequently asked questions
Is a civil RICO lawsuit a criminal case?
No. Civil RICO is a private damages claim. It carries no criminal penalty. The allegations should still be taken seriously and handled with awareness of any parallel exposure.
Can the insurer stop paying my claims while the case is pending?
Carriers often withhold or delay. Whether they lawfully can is itself a battleground, and pushing back on withheld reimbursements is part of the defense, not a separate problem.
Should I just settle?
Sometimes resolution is right; capitulation rarely is. Settlement value follows defense quality. A provider who mounts a real defense negotiates a different deal than one who folds at the complaint.
What is the Mallela theory?
In New York's no-fault context, carriers argue that a professional corporation that is in fact owned or controlled by non-physicians is not entitled to reimbursement. The defense turns on the actual ownership, the actual control of clinical decisions, and what the corporate and MSO documents establish.
Discuss a claim against your practice
Vorontsov Law Firm PLLC · 1599 E. 15th St., Ste. 4, Brooklyn, NY 11230
Related: Civil RICO Defense · MSO Agreements · Facing a Big Law Firm
