Sandra L. Heller
Partner
Overview
Sandra L. Heller leads Holland & Knight's Payer Dispute and Managed Care Litigation Team and focuses her national practice on managed care litigation and reimbursement disputes between providers and both private and governmental payers. Ms. Heller works closely with behavioral healthcare facilities, hospitals and health systems, physician groups, dental service organizations (DSOs), medical service organizations (MSOs), laboratories, pharmacies, home care providers, billing companies and other provider and provider-adjacent organizations to resolve reimbursement disputes efficiently and without disrupting provider-payer relationships.
As a former health insurance lawyer, Ms. Heller understands the importance of maintaining strong relationships with payers while concurrently defending the interests of a wide range of healthcare clients. From internal audits and investigations, resolution of denied or delayed reimbursement claims, process gaps around credentialing and claims adjudication, issues pertaining to the No Surprises Act and negotiation of network agreements, healthcare providers value Ms. Heller's experience on both sides of managed care disputes.
A skilled litigator, Ms. Heller has extensively litigated payer disputes for in-network and out-of-network providers in state, federal and administrative courts across the country, as well as in arbitrations administered by the American Arbitration Association (AAA) and Judicial Arbitration and Mediation Services (JAMS).
In addition, Ms. Heller has extensive experience with fraud, waste and abuse investigations in the healthcare space. She assists provider clients in responding to these allegations. Ms. Heller also guides and supports healthcare clients by implementing strategies resulting from key legislative changes and regulatory reporting responsibilities. She assists in fraud investigations throughout the U.S., and her work has created impactful and transformative case law in this arena.
In addition to her legal practice, Ms. Heller is an active speaker, often sharing her managed care dispute knowledge at conferences nationwide.
Before joining Holland & Knight in 2019, Ms. Heller was a board member and co-chair of the fraud and recovery practice group for a national law firm. She began her legal career as an assistant district attorney in Tarrant County in Fort Worth, Texas, where, among other things, she was a member of the elite Crimes Against Children Unit, in which she took more than 90 prosecutions to jury verdict.
Representative Experience
- Assisted a health system in a payer dispute involving miscalculation of chargemaster increases and resulting overpayment demand
- Assisted a health system in a payer dispute involving systematic downcoding and denials of high-acuity evaluation and management services
- Assisted a health system in renegotiating in-network provider agreements, resulting in higher reimbursements and aligning reimbursements
- Assisted a hospital in disputing "for cause" termination, resulting with withdrawal of termination notice
- Assisted a health system in disputing insufficient capitation payments resulting in underpayments in excess of $10 million
- Assisted physician practices and other providers in negotiating in-network contracts with regional and national health insurers
- Assisted a substance use disorder (SUD) treatment provider terminate prepayment review status based on an insurance special investigative unit investigation
- Assisted an autism therapy provider dispute delays in credentialing and resulting underpayments
- Assisted an eating disorder treatment provider end prepayment review status and obtained reimbursement on $2 million of impacted claims
- Assisted an SUD treatment provider dispute and overturned a multimillion-dollar overpayment demand from a Medicaid managed care organization
- Assisted a dermatology healthcare provider in appealing insurance special investigative unit-related overpayment/recoupment determinations from post-payment audits, resulting in the payer withdrawing millions of dollars in payment demands
- Assisted a gastroenterology healthcare provider in responding to and appealing a Medicaid managed care organization audit, resulting in the payer withdrawing a $1 million overpayment demand
- Assisted an emergency physician group in obtaining payment for downcoded and denied emergency evaluation and management claims
- Assisted a physical therapy provider in attaining payment on pending claims that were not timely adjudicated in violation of prompt pay statutes
- Assisted a pharmacy in negotiating in-network contracts
- Assisted a pharmacy in identifying "best practices" around compliance and payer reimbursement guideline awareness
- Assisted a pharmacy resist unsubstantiated termination for cause
- Assisted a DSO resist improper network termination of providers and obtained reinstatement status
- Assisted a DSO and related practices dispute healthcare administration rule promulgation for Medicaid services that unfairly impacted dental providers
- Assisted a dental practice in overturning a managed care organization overpayment demand for dental services in an administrative hearing
- Assisted an emergency ambulance transport client address claim denials and navigate the Independent Dispute Resolution (IDR) process
- Assisted a provider group and air ambulance provider in seeking a solution to unpaid IDR awards
- Assisted provider groups and air ambulance providers in seeking and obtaining in-network status
- Represented a national health insurer in federal court against substance use disorder (SUD) facility and associated laboratory, detox facility and marketing arm involving claims of fraud, violations of Florida's Deceptive and Unfair Trade Practice Act (FDUTPA) and unjust enrichment pertaining to performance of unnecessary and unlawful urine drug testing, as well as the inappropriate use of marketing entities and the unlawful brokering of patients
- Represented a national health insurer in an action in which counterclaims were advanced against related SUD providers in numerous states alleging schemes involving patient brokering, referrals for unnecessary and non-U.S. Food and Drug Administration (FDA)-approved ancillary services and violations of the federal Elimination of Kickbacks in Recovery Act (EKRA)
- Represented a national health insurer as a creditor in a bankruptcy action in which a SUD facility that was the subject of district court litigation sought relief via a Chapter 7 action
Credentials
- Texas Tech University School of Law, J.D.
- Texas A&M University, B.B.A., Management
- Florida
- Texas
- U.S. Court of Appeals for the Eleventh Circuit
- U.S. District Court for the Middle District of Florida
- U.S. District Court for the Southern District of Florida
- U.S. Supreme Court
- Association of Certified Fraud Examiners
- Florida Insurance Fraud Education Committee, Certified Trainer
- International Association of Special Investigation Units (IASIU), Certified Trainer
- Medical Claims Defense Network, Certified Trainer
- Broward County Bar Association
- Florida Association of Women Lawyers
- Florida Super Lawyers magazine, 2020-2022
- Holland & Knight Pro Bono All-Star, 2020
- The Legal 500 USA, ERISA Litigation, 2021
