Frank P. Fedor

Frank P. Fedor

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Frank Fedor is a partner and leads the firm's Healthcare Practice Team. He has successfully represented healthcare providers in obtaining or defending over $100 million in disputes with managed care payers and in Medicare reimbursement appeals.

Frank is an AV® Peer Review Rated lawyer and was recognized in 2008 and 2009 as a Northern California Super Lawyer® in the field of healthcare. Representative listings of Frank’s experience, public speaking, and writing in his areas of focus are presented below.

Frank is experienced in trial, litigation, arbitration, mediation, and other dispute resolution venues. He has practiced litigation since 1983. In 1993 Frank graduated from the National Institute for Trial Advocacy Western Regional Program given at the University of California, Berkeley. He was a member of the Milton L. Schwartz American Inn of Court at the University of California, Davis School of Law from 1992 to 1993. Frank has spoken extensively for California Continuing Education of the Bar and other program sponsors on trial and litigation topics such as trial evidence, trial objections, oral presentation tactics, law and motion practice, and the attorney- client privilege.

Frank served from 2004-2005 as President of the Northern California Chapter of the Healthcare Financial Management Association (HFMA). From 1998 to 2000 he was the founding Chairperson of the Compliance Committee of HFMA’s Northern California Chapter which sponsors educational programs and networking sessions for compliance professionals. From 1997 through 1998 Frank was General Counsel for the Center for AIDS Research, Education and Services (CARES), an outpatient clinic established by a consortium of leading healthcare providers for the purpose of treating the AIDS epidemic in Northern California.

Immediately after graduation from Duke University School of Law in 1983, Frank served as a judicial clerk to Justice Christine M. Durham of the Utah Supreme Court. During this judicial clerkship he assisted Justice Durham in the opinion of Utah County v. Intermountain Health Care, Inc., 709 P.2d 265 (1985), an early case on the issue of tax exemptions for non-profit hospitals.

Before receiving his undergraduate degree from the University of California at Berkeley in 1980, Frank served from 1974 to 1977 with the United States Army. His service was primarily with the 2d Battalion, Mechanized 60th Infantry, of the Ninth Infantry Division at Fort Lewis, Washington, where he rose to the rank of Sergeant.

REPRESENTATIVE EXPERIENCE

Representative of Frank’s experience in representing providers in enforcing their managed care contracts and in other disputes are the following:

• Obtained arbitration award of over $325,000 after establishing the medical necessity of continued inpatient hospital services to a patient with medical and psychiatric issues, including application of Welfare and Institutions Code § 5150 “danger to self” standard.
• Obtained arbitration award of over $1,700,000 after establishing that transfer of a newborn with multiple birth defects was an “emergency transfer” under a managed care contract.
• Obtained $35 million group settlement with Medicare for SNF exception payments to hospitals due to the 112% peer group mean “gap.”
• Lead counsel in four-week jury trial determining the reasonable value of non-contracted emergency services provided to members of Kaiser Foundation Health Plan.
• Obtained full recovery settlements for four university medical centers and affiliated medical groups in separate contract arbitrations against a health plan that retroactively recouped capitation payments on the basis of a unilateral percentage-of-premium capitation rate reduction by the plan.
• Obtained arbitration award exceeding $2,100,000 on behalf of hospital and affiliated medical group in arbitration against a health plan to recover payment under a transplant pool arrangement for transplant related services rendered to a plan member by a transplant center.
• Successfully represented university medical center in wide variety of contract disputes concerning transplant services.
• Successfully represented university medical center and affiliated medical group in arbitration against a health plan to recover payments under an adverse selection provision.
• Settled or obtained arbitration awards for trauma center in various trauma rate disputes, including the qualification of a patient as a “trauma case” under the applicable trauma triage criteria.
• Obtained full-value settlements for hospitals in contract rate disputes concerning health plans downcoding and “repricing” hospital charge master charges to reduce total charges in stop loss and other percent of charges contract rates.
• Recovered over $15 million in summary adjudication in arbitration, arbitration awards, and settlements for university medical centers and hospitals in contract rate disputes concerning a health plan’s bundling charge master charges to reduce total charges in stop loss and other percent of charges contract rates.
• Successfully represented hospitals in contract disputes concerning health plans reducing level of care to reduce per diem or percent of charges rates.
• Successfully defended university medical center in a $20 million claim for audit disputes concerning rejection of charges for routine rooms, supplies, “incremental nursing,” anesthesia services and medications, alleged “call-back” services, pre-operating rooms, operating rooms, recovery rooms and payment based on DRGs.
• Successfully represented hospitals in disputes concerning scope of audit, time limits for audits, and “late charges.”
• Represented hospitals in arbitrations, administrative hearings, or state and federal court civil actions concerning a wide variety of other miscellaneous issues including medical necessity, the applicability of evergreen clauses in the context of good faith contract negotiations, and the adjustment of capitation rates upon a carve-out of services.
• Represented trauma center in prosecuting administrative claims before the California Department of Health Services against a health plan for payment for emergency services rendered to Medi-Cal Geographic Managed Care (“GMC”) members at the Medi-Cal interim rate.
• Represented trauma center in prosecuting administrative claims before the California Department of Health Services against several health plans for payment for emergency services rendered to Medi-Cal Two-Plan Model members at the Medi-Cal interim rate.
• Represented hospital in prosecuting claims against several Medi-Cal County Organized Health Systems (“COHS”) for payment for emergency services rendered to Medi-Cal members at the Medi-Cal interim rate.
• Represented hospitals in claims against a state government entity to recover payment for emergency services.
• Represented school of medicine in prosecuting claims against former faculty member for breach of faculty compensation plan resulting in settlement.
• Represented providers in the litigation of disputes under the California False Claims Act.

SPEAKING ENGAGEMENTS

• Enforcing Your Managed Care Contracts, UC Davis Medical Center, Davis, CA, April 26, 2011
• New Issues Affecting Non-Contracted Emergency Services, Northern California HFMA Spring Conference, Sacramento, March 24, 2011
• Payment for Non-Contracted Hospital Emergency Services, The Southern California Chapter of HFMA, San Bernardino, February 19, 2010
• Payment for Non-Contracted Hospital Emergency Services, The Southern California Chapter of HFMA, Western Med, Santa Ana, February 18, 2010
• Payment for Non-Contracted Hospital Emergency Services, The Southern California Chapter of HFMA, Bakersfield, February 17, 2010
• Payment for Non-Contracted Hospital Emergency Services, The Northern California Chapter of HFMA, Sutter Center for Health Professionals, Sacramento, November 6, 2009 Payment for Non-Contracted Hospital Emergency Services, ValleyCare Health System, Pleasanton, October 30, 2009
• Contracting from the Legal Perspective - Getting the Contract Right, Panel Discussion, HFMA Northern California Spring
• Conference, Rancho Cordova, April 30, 2009
• Payment for Non-Contracted Hospital Emergency Services, Northern and Southern California Healthcare HFMA Chapters California Fall Conference, Newport Beach, September 14, 2008
• Negotiating Managed Care Agreements, MGMA Administrators in Oncology/Hematology Assembly Conference, Myrtle Beach, April 19, 2005
• Enforcing Your Managed Care Contracts: Stand Up For Your Rights, Healthcare Financial Management Association Twelfth Annual Conference On Managed Care, San Francisco, September 27, 2002
• Enforcing Your Managed Care Contracts: A Legal View, Healthcare Financial Management Association Annual National Institute, Seattle, June 17, 2002
• Enforcing Your Managed Care Contracts, Lorman Education Services, September 12, 2001 - Sacramento
• Avoiding the Hidden Pitfalls in Managed Care Contracts, Healthcare Financial Management Association National Audio-Teleconference, June 6, 2001
• Enforcing your Managed Care Contracts, Lorman Education Services, April 18, 2001 - San Francisco
• Ethical Obligations and Legal Risks When Advising Health Care Clients, Sacramento County Bar Association, Health Law Section, February 15, 2001 - Sacramento
• Integrating Agents Into Your Compliance Program, Healthcare Financial Management Association, Third Annual Region II Healthcare Symposium, January 16, 2001 - Las Vegas
• Key Developments In Medicare In California, Lorman Education Services, October 5, 2000 - SacramentoManaging Your Managed Care Contracts, Lorman Education Services, August 18, 2000 - Sacramento
• Managed Care Liability, Department of Family Medicine, University of California, Davis School of Medicine, March 2, 2000 - Sacramento
• Managed Care Liability, Department of Ophthalmology, University of California, Davis School of Medicine, October 29, 1999 - Sacramento
• Managed Care Liability, Department of Orthopaedics, University of California, Davis School of Medicine, September 14, 1999 - Sacramento
• Compliance Update for Patient Financial Services, Healthcare Financial Management Association, Northern California Chapter, February 26, 1999 - Sacramento
• Cost Effective Compliance Strategies for Smaller Organizations, Second Annual National Congress on Health Care Compliance, February 12, 1999 - Washington, D.C.
• Cost Effective Compliance, Child Health Corporation of America, December 11, 1998 - Chicago
• Compliance for the Small Provider, American Health Lawyers Association, Annual Conference, June 28 - July 1, 1998 - San Diego
• Compliance Issues in Outsourcing Arrangements, American Health Lawyers Association Institute on Medicare and Medicaid Payment Issues, March 25-27, 1998 – Baltimore

PUBLICATIONS

Seminole Rock: Ready to Crack and Crumble?, HFMA Northern California Newsletter, The Edge, January 2012

What Does A County Owe for Non-Contracted Emergency Services?, HFMA Northern California Newsletter, The Edge, November 2011

The Impact of Howell v. Hamilton on the Reasonable Value of Non-Contracted Emergency Services, HFMA Northern California Newsletter, The Edge, September 2011

Why California Medicare Appeals Should Go East, HFMA Northern California Newsletter, The Edge, April 2011

Lions and Tigers Threaten the Validity of Medicare Rules, HFMA Northern California Newsletter, The Edge, February 2011

Medicare’s Time Limit for DGME and IME Claims Associated With Part C Services is Rejected by the D.C. Circuit, HFMA Northern California Newsletter, The Edge, January 2011

Effects of the New 2008 PRRB Rules and Regulations on Group Appeals, Co-authored with Jenny M. Phillips, HFMA Northern California Newsletter, The Edge,  October 2008

What’s Mine is Mine, What’s Yours is…Mine—Noncontracted Services and Discounted Rates, Healthcare Financial Management, September 2008

The Conflict between ERISA and Local Healthcare Reform, Co-authored with River Sung, Healthcare Financial Management, May 2008

A Close Call for ‘Usual Charges’, Healthcare Financial Management, September 2007

Independent Dispute Resolution Process, Healthcare Financial Management, May 2007

Reasonable Value of Noncontracted Emergency Services, 3 Health Plan Myths, Healthcare Financial Management, January 2007

ERISA and Hospital Charges: Granting an Inch, Not a Mile, Healthcare Financial Management, September 2006

The Balancing Role of Balance Billing, Healthcare Financial Management, May 2006

Unbundling the Confusion About "Unbundling" of Charges, Healthcare Financial Management, January 2006

Recovery Audit Contractors "RAC" Up Another Challange for Providers, Healthcare Financial Management, September 2005

Contracted Payers: The Latest Challengers to Hospital Billed
Charges, Healthcare Financial Management, May 2005

Cutting to the Heart of the Theory: The Latest on Charity Care Litigation, Healthcare Financial Management, March 2005

Changing Views About "Usual Charges," Healthcare Financial Management, January 2004

Medicare Does Not Govern Commercial Contract Rates, HFMA Northern California Newsletter, The Edge, December 2003

An Arbitration Primer For Providers, Healthcare Financial Management, November 2002

Model Contract Language Guide, VHA West Coast, September, 2001 (with the VHA West Coast Contract Language Workgroup)

Resolving Conflicts Between EMTALA And Managed Care Requirements, Healthcare Financial Management, September 2001 (with Anthony M. Perez)

New Statute Reduces The Value Of Liens For Payers, HFMA Northern California Newsletter, The Edge, April 2001

The Top Ten Pitfalls In Managed Care Contracts, Healthcare Financial Management, April 2001 (with Anna Orlowski)

A New Era Of Prompt Payment Dawns, HFMA Northern California Chapter Newsletter, The Edge, March, 2001

Another Provider Victory In The False Claims Act War, HFMA Northern California Chapter Newsletter, The Edge, February 2001

Percentage Compensation Arrangements: Suspect But Not Illegal, Healthcare Financial Management, January 2001

New False Claims Act Developments Help Providers, HFMA Northern California Chapter Newsletter, The Edge, December 2000.

Oversight Of Contractors/Subcontractors, Chapter 650, Health Care Program Compliance Guide, Bureau of National Affairs, Summer 2000

Cost Effective Compliance For The Small Provider, Healthcare Financial Management, July, 2000

Healthcare Provider Compliance Issues, (Chapters 1 and 3), Issues Collection Series, American Health Lawyers Association, March 1999

New Exclusions and Penalties Underscore Importance of Compliance Programs, Healthcare Financial Management, December 1998

Compliance Plans For The Small Provider, American Health Lawyers Association Program Materials, Annual Meeting, June 1998

Outsourcing: Opportunities for Better Performance and Compliance, American Health Lawyers Association Program Materials, Nineteenth Annual Institute on Medicare and Medicaid Payment Issues, March 1998

PUBLISHED AND PUBLICALLY AVAILABLE CASES

Loma Linda University Medical Center v. Sebelius, 684 F.Supp.2d 42 (D.D.C. Feb 16, 2010) Affirmed by Loma Linda University Medical Center v. Sebelius , 2010 WL 4903887 (D.C.Cir. Dec 02, 2010)

Loma Linda University Medical Center (Loma Linda, Cal.) v. Blue Cross Blue Shield Assoc., PRRB Hearing, Dec. No. 2008-D26, CCH Medicare and Medicaid Guide 81.888 (May 9, 2008)

Mercy Medical, Alameda Hospital, Providence Centralia Hospital v. Thompson, 2004 WL 3541332 (U.S. D.C. District of Columbia 2004)

San Joaquin Community Hospital v. Thompson, 2002 WL 34596496 (E.D. Cal.).

St. Luke’s Methodist Hospital v. Thompson, 315 F.3d 984 (8th Cir. 2003)

St. Luke’s Methodist Hospital v. Thompson, 182 F.Supp.2d 765 (N.D. Iowa 2001)

The University Of California Davis Medical Center v. Omni Healthcare, Inc., Department of Health Services, State of California, Administrative Hearing re: Emergency Services Claims Disputes, Final Decision April 24, 1998

Alameda Hospital-Skilled Nursing Facility (Alameda, CA) v. Blue Cross Blue Shield Association /United Government Services, LLC-CA, PRRB Hearing Dec. No. 2002-D46, CCH Medicare & Medicaid Guide 80,905 (Sep. 27, 2002)

Colleton Regional Hospital-Skilled Nursing Facility (Waterboro, SC) v. Blue Cross Blue Shield Association/Blue Cross Blue Shield of South Carolina, PRRB Hearing Dec. No. 2002-D8, CCH Medicare & Medicaid Guide 80,795 (Feb. 21, 2002)

Centennial Medical Center -Skilled Nursing Facility (Nashville, TN) v. Blue Cross Blue Shield Association/Blue Cross Blue Shield/ Riverbend Government Benefits Administrator, PRRB Hearing Dec. No. 2001-D54, CCH Medicare & Medicaid Guide 80,745 (Sept. 28, 2001)

Newman Memorial County Hospital (Emporia, KS) v. Blue Cross Blue Shield Association/Blue Cross and Blue Shield of Kansas, Inc., PRRB Hearing Dec. No. 2001-D41, CCH Medicare & Medicaid Guide 80,731 (May 15, 2001)

San Joaquin Community Hospital-Skilled Nursing Facility (Bakersfield, CA) v. Blue Cross Blue Shield Association/Blue Cross of California, PRRB Hearing Dec. No. 2001-D17, CCH Medicare & Medicaid Guide 80,654 (April 17, 2001)

Mercy General Hospital v. Blue Cross Blue Shield Association/Blue Cross of California, PRRB Hearing Dec. No. 2000-D87, CCH Medicare & Medicaid Guide 80,572 (Sept. 22, 2000)

Fort Bend Community Hospital - Skilled Nursing Facility (Missouri City, TX) v. Mutual of Omaha Insurance Company, PRRB Hearing Dec. No. 2000-D86, CCH Medicare & Medicaid Guide 80,571 (Sept. 21, 2002)

St. Luke’s Methodist Hospital-Skilled Nursing Facility (Cedar Rapids, Iowa) v. Blue Cross Blue Shield Association/Blue Cross and Blue Shield of Iowa, PRRB Hearing Dec. No. 2000-D11, CCH Medicare & Medicaid Guide 80,386 (Dec. 14, 1999)

Riverview Medical Center - Skilled Nursing Facility (Gonzales, LA) v. Mutual of Omaha Insurance Company, PRRB Hearing Dec. No. 99-D67, CCH Medicare & Medicaid Guide 80,331 (Sept. 2, 1999)

LEADERSHIP POSITIONS

• Healthcare Financial Management Association, Northern California Chapter
  President (2005 - 2006)
  President-Elect (2004 - 2005)
  Secretary (2003 - 2004)
  Member of the Board of Directors (2001 - 2007)
  Chair/Co-Chair Compliance Committee (1998 - 2003)
  

• General Counsel, Center for AIDS Research Education and Services (CARES) (1997 to 1998)
  

• Pro Tem Settlement Judge, Sacramento County Superior Court
  

• Arbitrator, Sacramento County Superior Court

BAR ADMISSIONS

• California

• Supreme Court of the United States

• United States Court of Appeals for the District of Columbia Circuit

• United States Court of Appeals for the Fifth Circuit

• United States Court of Appeals for the Eighth Circuit

• United States Court of Appeals for the Ninth Circuit

• United States District Court for the Eastern, Northern, Central and Southern Districts of California

EDUCATION

• Duke University School of Law
  J.D., 1983
  William Neal Reynolds Scholarship
  

• University of California at Berkeley
  B.A., 1980
  Phi Beta Kappa

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