Helaine I. Fingold

Overview

When clients need help understanding the federal and state regulation of health insurance, and identifying and addressing related barriers and opportunities, they turn to attorney Helaine Fingold.

Clients benefit from Helaine’s experience working at both the Centers for Medicare & Medicaid Services and the Medicare Payment Advisory Commission (MedPAC), which has given her keen insight into how regulators interpret and apply the laws, regulations, and related administrative processes regarding Medicare, Medicaid, and commercial insurance.

Her clients range from small start-ups to large corporate entities with multiple subsidiaries. They include Medicare Advantage, PACE, Medicaid, and other managed care plans; provider entities; vendors to providers and managed care companies (including administrative support entities, providers of software and online services, agents/brokers/field marketing organizations, and advertising/marketing entities).

Helaine’s practice focuses largely on the regulation of Medicare managed care (including Medicare Advantage, Part D, dual eligibles, PACE, demonstrations), Medicaid managed care, commercial managed care products (including surprise billing), and behavioral health (including mental health parity).

Helaine helps clients:

understand and address state licensure rules that apply to their business;
develop and submit Medicare Advantage, Qualified Health Plan, and other managed care applications for qualification;
respond to deficiencies in Medicare Advantage applications;
appeal the denial of a Medicare Advantage application;
challenge and get withdrawn federally issued compliance notices for allegedly failing to comply with Medicare Advantage regulations and guidelines;
identify and correct noncompliance with Medicare managed care laws and regulations;
identify health regulatory compliance risks in potential investments through due diligence reviews;
understand applicable rules, and appeal Medicare star ratings; and
understand and interpret the new federal law on surprise billing, including areas for potential regulatory governance.

Before building her private practice, Helaine gained 20 years of experience in the federal government: 13 years at CMS, working on Medicaid, Medicare Advantage/Part D, and ACA implementation, and seven years at MedPAC. During her time at CMS, she was part of the team that implemented the Medicare Advantage program prior to its rollout in 2006. She also worked with the team that implemented the Affordable Care Act requirements applicable to federal and state health care marketplaces, qualified health plans, and individual and small group commercial insurance. Helaine’s government experience also included serving as General Counsel for the Medicare Payment Advisory Commission.

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Experience

Represented a vendor supporting providers and payors in claims processing and other administrative tasks. Helaine assisted the client with research on Medicaid rules for each of the 50 states regarding the ability of managed care plans and their downstream entities to use non-U.S. employees and subcontractors. She coordinated and guided a team of associates in completing the research and explained the results to her client.
Provided representation to a national Medicare managed care plan on its corporate restructuring efforts. Helaine advised the client on Medicare rules regarding changes of ownership and the resulting impact on options for corporate restructuring. She assisted in drafting materials for submission to CMS, and the client’s restructuring initiative was approved by CMS.
Represented a utilization management company that sought approval by CMS as a provider-led entity (PLE) offering Medicare appropriate use criteria. Helaine researched and reviewed regulatory requirements as well as applications of entities previously reviewed and approved or denied as a PLE. The client was successfully approved as a PLE.
Won approval for a national managed care plan to offer Medicare Advantage products in its requested service area.
Represented a vendor to commercial managed care plans that sought analysis of its offerings to demonstrate to potential clients that its offering could be considered quality improvement activities under medical loss ratio (MLR) rules.
Provided representation to a managed care plan that sought assistance in developing a corporate and regulatory strategy for offering Medicare managed care joint ventures to maximize expenses qualifying as clinical services under MLR rules.

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