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 managed care attorneys are known for their 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. Our managed care lawyers 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. Our managed care attorneys 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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Events
Upcoming Events
Past Events
- December 2024
- Fall 2024
Insights
Insights
- Media CoverageWilliam Walters Quoted in “Trump's Federal Assistance 'Pause' Axed Following Confusion, Litigation, System Outages” ...5 minute read
- Media CoverageRichard Hughes Quoted in “Trump Spending Freeze Sparks Pandemonium in Health Sector”1 minute read
- Media CoverageRichard Hughes Quoted in “Trump Directive on Grants Spurs Uncertainty for Health Programs”2 minute read
- Media CoverageHelaine Fingold Quoted in “Trump Regulation Freeze Could Put Chill on Medicare Advantage Funding”2 minute read
- Media CoverageRichard Hughes Quoted in “ACA Suit Threatens Overhaul of Preventive Care in Employer Plans”2 minute read
- Media CoverageRichard Hughes Quoted in “How RFK Jr. Drove Mistrust of a Cancer Prevention Vaccine”7 minute read
- Media CoverageHelaine Fingold Quoted in “Trump 2.0 Faces Lingering Legal Questions Regarding RADV Audits, Stars, Broker Pay” ...3 minute read
- Media CoverageRichard Hughes Quoted in “Supreme Court Case Offers Trump Path to Dismantle Obamacare Mandates”5 minute read
- Media CoverageRichard Hughes Quoted in “Supreme Court to Hear ACA Preventive Coverage Suit”4 minute read
- Media CoverageRichard Hughes Quoted in “Supreme Court to Hear ACA Preventive Care Case”1 minute read
- Media CoverageRichard Hughes Quoted in “Biden Admin Finalizes NBPP, MA Pay Rules Ahead of Departure”2 minute read
- Media CoverageRichard Hughes Quoted in “SCOTUS to Review ACA’s Free Preventative Services Mandate”2 minute read
- Media CoverageRichard Hughes Quoted in “Obamacare Case Presents Renewed Opportunity to Restrict Agencies”4 minute read
- PublicationsCMS Rule for CY 2026 Highlights AI, Behavioral Health, Anti-Obesity Drug Coverage, and More24 minute read
- Media CoveragePhilo Hall Quoted in “A Medicare Minefield Awaits Oz”2 minute read
- BlogsPodcast: Health Policy Update: Impact of the 2024 U.S. Elections – Diagnosing Health Care2 minute read
- Media Coverage
Kevin Malone Featured in AHLA’s Speaking of Health Law Podcast, “Mental Health Parity: The New Legal and Regulatory ...
1 minute read - Firm AnnouncementsEpstein Becker Green Announces 2025 Promotions4 minute read
- BlogsCMS Issuing First Risk Adjustment Data Validation Audit Notices for PY2018 Since the RADV Final Rule1 minute read
- BlogsPost-Hurricane Flexibilities Offered by the U.S. Department of Health and Human Services Through the Centers for Medicare & ...3 minute read
- Media CoverageRichard Hughes Quoted in “5 Ways Trump's Election Could Change Employee Benefits”2 minute read
- Media CoverageMark Lutes Quoted in “Trump Win Tees Up Regulatory Rollbacks and Uncertainty”3 minute read
- Media CoverageStuart M. Gerson Quoted in “HHS Hospital Pay Formula at High Court: 4 Things to Know”3 minute read
- PublicationsThe US Supreme Court and the Uncertain Future of Preventive Care4 minute read
- Media CoverageRichard Hughes Quoted in “Gov't Looks to High Court to Preserve Free Preventive Care”2 minute read
- Media CoverageRichard Hughes Quoted in “DOJ Asks SCOTUS to Reverse Braidwood Ruling, Uphold ACA’s Preventative Mandate” ...3 minute read
- Media CoverageKevin Malone Quoted in “Mental Health Parity Rule Pushes Employers to Rethink Status Quo”3 minute read
- Media CoverageRichard Hughes Quoted in “CMS Signals Preventive Services Coverage Update with Pending Rule”3 minute read
- Media Coverage
Richard Hughes Quoted in “DOJ Will Ask SCOTUS to Take Up Braidwood”
3 minute read - Media CoverageMarjorie Scher Quoted in “Will Medicaid Incarceration Waivers Hit 'Cutting Room Floor'?”2 minute read
- Media CoverageChristine Worthen Featured in “Beltway Moves”1 minute read
- Media CoverageEpstein Becker Green Adds Healthcare Attorney Christine Burke Worthen in Washington, DC2 minute read
- Firm AnnouncementsEpstein Becker Green Adds Health Care Regulatory Firepower with Attorney Christine Burke Worthen in Washington, DC ...2 minute read
- BlogsCMS Rules Propose Changes Regarding the Medicare Prescription Drug Inflation Rebate Program, Refundable Drugs, Skin ...13 minute read
- PublicationsCMS Issues Mandatory “TEAM Model” for Acute Care Hospitals to Improve Episode-Based Alternative Payments and Advance ...17 minute read
- BlogsAffordable Care Act Overpayments in the CY 2025 Medicare Physician Fee Schedule Proposed Rule: Implications for False ...10 minute read
- Publications
Supreme Court Alters the Administrative State: Loper and Relentless Decision Shifts Authority from Administrative ...
13 minute read - Media CoverageDavid Shillcutt Quoted in “Illinois Bans Step Therapy, Health Plan Prior Authorization for Emergency Mental Health ...3 minute read
- Media CoverageHelaine Fingold Quoted in “MAOs, Brokers, Agents Get Relief with Legal Pause on Policy Changes”2 minute read
- Media CoverageHelaine Fingold Quoted in “Court Pauses CMS Broker Compensation Rule for Medicare Advantage Plans”3 minute read
- Media CoverageRichard Hughes Quoted in “Insurance Wouldn’t Pay for His Vasectomy. Such Birth Control Coverage May Become More ...2 minute read
- PublicationsNew Anti-Obesity Medications Should Be Considered Preventive Health Care2 minute read
- Media CoverageMandated Coverage of Biomarker Testing: Q&A with Robert Hearn4 minute read
- Media Coverage
Robert Wanerman Quoted in “Health Regulators Likely to Tread Carefully Post-Chevron”
2 minute read - Media Coverage
Richard Hughes Quoted in “Supreme Court Overrules Chevron Deference, Dealing Blow to Federal Healthcare Agencies” ...
3 minute read - PublicationsBraidwood v Becerra: The Threat to Preventive Services Just Got Worse3 minute read
- Media CoverageRichard Hughes Quoted in “Feds' 5th Circ. Win on Preventive Care May Imperil ACA”3 minute read
- Media CoverageRichard Hughes Quoted in “Obamacare Mandate Battle Shifts After Appeals Court Speaks”3 minute read
- Media CoverageRichard Hughes Quoted in “Court Upholds ACA’s Free Preventive Services Mandate”3 minute read
- Media CoverageRichard Hughes Quoted in “‘A Mixed Bag’: Fifth Circuit Rules on ACA Preventive Services Legal Case”3 minute read