Overview
As managed care plans grow and adapt both to an unsettled health care market and to the constant changes in its legal and regulatory landscape, sophisticated help is a necessity. The attorneys in our Managed Care practice group help plans of every size—as well as the full spectrum of providers, payors, and vendors in their ecosystem.
Understanding Compliance Requirements
Our team is known for its comprehensive grasp of the federal laws and regulations governing managed care plans, but that’s only a start. Each state has its own regulatory framework, and the ability to respond to new initiatives from state to state is both necessary and daunting—few companies can do it for themselves. At each stage in the life cycle of a company, we help our clients navigate the myriad complexities of the compliance requirements expected of them.
Aligning Incentives
The ability to get plans and the providers they contract with to agree on the sharing of financial or insurance risk is a particular strength of ours. We regularly advise clients on both sides of that table on the risk assumption and payment strategies available to them. The goal is to align the incentives of both plans and providers, preserving efficiencies and maintaining compliance while delivering appropriate standards of service to patients.
Providers Joining Plans
Provider networks of all kinds (hospitals, physicians, behavioral health, telehealth, laboratories, etc.) turn to us to do the necessary legal work to integrate them into the managed care ecosystem. We do their initial corporate structuring, establishing them as entities fully compliant with all regulatory requirements. We draw up their network participation contracts, locking in favorable payment methodologies and protections against reimbursement denials. We negotiate and draft their downstream agreements with administrative and ancillary services. In addition, we arrange new types of joint ventures between providers and plans, a development we expect to see much more of in the future.
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Experience
- Helped Medical Card Systems (MCS), one of the largest managed care organizations in Puerto Rico, secure a double bonus for a high Star rating after our team convinced the Centers for Medicare & Medicaid Services (CMS) to change its policy of excluding otherwise eligible Puerto Rico counties from double bonuses. This policy change increased Medicare Advantage reimbursements to MCS by 4 to 5 percent.
- Negotiated, on behalf of a highly regarded academic medical center, long-term joint-venture-like agreements with New York State managed care organizations. Besides drafting insurance risk-sharing value-based payment contracts, we advised the client on related federal and state health care and insurance laws and regulations.
- Advised a large health plan on co-branded products and joint venture and risk-sharing contracts with a large hospital system.
- Serves as outside counsel to a fast-growing national telebehavioral health company on regulatory, compliance, contracting, privacy and security, and other matters.
- Counsels hospital systems and other types of providers on value-based reimbursement contracts with plans and other payors, and assists with related regulatory and dispute resolution matters.
- Advises start-up companies offering disease management and care management networks and services.
- As seconded general counsel for a regional managed care plan, advised on all legal and regulatory matters for government programs, including compliance counseling, audit preparation, and defense on Medicare Advantage, fully integrated dual eligible Medicare Advantage special needs plans (FIDE-SNP), Medicaid managed care, Programs of All-Inclusive Care for the Elderly (PACE), exchange plans, fully insured commercial insurance plans, and third-party administrator products for self-funded group health plans.
- Advised numerous provider and managed care clients on new health care payment and delivery models being advanced through CMS and the Center for Medicare and Medicaid Innovation. We drafted comment letters, attended meetings with CMS, and assisted in preparations for participation in bundled payment programs.
- Drafted medical group leases, services contracts, and employment arrangements for various managed care organizations.
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- Firm AnnouncementsEpstein Becker Green Announces 2024 Promotions6 minute read
- BlogsThe Guiding an Improved Dementia Experience (“GUIDE”) Model9 minute read
- Media CoverageRachel Snyder Good Quoted in “'Devil's in the Details' of Biden's AI Health Plans, Experts Say”3 minute read
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- Media CoverageHelaine Fingold Quoted in “Reports of Cold Calling, False Promises Put Medicare Marketers on Alert”3 minute read
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- Media Coverage
Richard Hughes Featured in STAT First Opinion Podcast, “How to Save PrEP Access — and Even Expand It”
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- Publications
How to Protect PrEP Coverage, No Matter What Happens in Braidwood v. Becerra
3 minute read - PublicationsBy Leaving "Therapeutic Alternatives" Undefined, CMS Tilts the Playing Field of Drug Price Negotiations3 minute read
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- Media CoverageRichard Hughes Quoted in “Biden's Next Steps on Preventive Services Coverage”3 minute read
- PublicationsIs CMS Ignoring the Realities of Biopharmaceutical Costs?2 minute read
- Publications
Repairing the US Preventive Services Task Force After Braidwood v. Becerra
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- PublicationsCMS Can Fix Medicare Vaccine Coverage to Protect Seniors from RSV4 minute read
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- Media CoverageInsulin as Preventive Care: Why Not Eliminate Patient Cost Sharing?4 minute read
- PublicationsA Patchwork in Need of Permanent Repair: The U.S. Framework for Recommending and Covering Preventive Care2 minute read
- Firm Announcements
Epstein Becker Green Recognized Among Top 10 Largest Health Care Law Firms by Modern Healthcare
2 minute read - Media CoverageRichard Hughes Quoted in “Moderna Will Charge Around $130 for Its COVID Vaccine — and Congress Isn’t Too Happy” ...3 minute read
- PublicationsReflecting on the Future of US Vaccine Programs2 minute read
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