As managed care plans grow and adapt both to an unsettled health care market and to the constant changes in its 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 an 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.
Representative 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 large hospital system.
- Serves as outside counsel to 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 assist 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.