Overview
Our attorneys provide managed care regulatory, compliance and operations advice to health plans, health insurers, third party administrators and provider organizations of all sizes on a national basis. Several of our attorneys have significant government agency experience. Our experience includes:
- ERISA
- Fraud and abuse
- HIPAA and state law privacy and security matters
- State HMO and insurance laws
- Medicaid managed care
- Medicare Advantage plans
- Mental health parity
- Peer review and credentialing
- PPACA Implementation
- Specialty health plans (including behavioral health, vision, dental, chiropractic and acupuncture)
- Discount programs
- Disease management
- Utilization review and medical bill review
- Workers’ compensation
Our representative projects include:
- Health Care Reform: Assisted clients in developing and implementing compliance plans and strategic initiatives in response to federal health care reform
- Change of Ownership Approvals: Represented numerous large and small health plans and insurers in obtaining regulatory approvals for changes of ownership.
- Medicaid Managed Care: Represented health plan association in developing a plan agreeable to state regulators which allowed Medi-Cal managed care plans in California to receive additional state and federal funding.
- Peer Review and Credentialing: Represented a large national health organization in reviewing and analyzing peer review laws for all 50 states; developed a comprehensive electronic report explaining the results of the review and analysis.
- Workers’ Compensation: Represented workers’ compensation carrier in review and analysis of managed care systems and policies, including utilization review, PPO networks and medical bill review.
Medicare Advantage
Our attorneys represent health plans and other managed care organizations with matters involving Medicare managed care. This history has involved client representation under the Medicare Risk program, the Medicare + Choice program and the Medicare Advantage program adopted by the Medicare Modernization Act. Our clients include large national health plans and smaller regional and local Medicare Advantage plans. Our experience includes the following:
- Compliance with CMS regulations and guidelines
- Fraud and abuse
- Marketing and broker agreements
- OIG audit assistance
- Physician-incentive program compliance
- Preemption of state laws
- Retiree benefit plans
- Value-added items and services
Our representative projects include:
- Medicare Preemption: Obtained an injunction in federal district court against California state regulator prohibiting enforcement of numerous state laws based upon federal preemption.
- Medicare Demonstration Project (ESRD): Assisted health plan client in obtaining regulatory approval and developing risk-allocation and service contracts to support Medicare demonstration project for coverage of ESRD patients.
- Marketing Contracts: Developed contracts with field marketing organizations, general agents and solicitor agents for sale of Medicare Advantage Plans (supporting HMO, private fee-for-service and Medicare Part D programs) to reflect regulatory guidance from CMS and analyzed compliance with fraud and abuse laws.
- Multi-State Medicare Advantage PPO Research: Review and analyze state-law licensing and regulatory requirements applicable to insurers and PPO networks in connection with Medicare Advantage PPO products to be offered in 47 states.
Managed Care Contracting
Attorneys at Locke Lord represent managed care plans in developing and negotiating provider contracts with physicians, multi-specialty physician groups, IPAs, hospitals and ancillary providers. Our attorneys have developed health plan contracts with capitated providers that have served as models for the industry. Firm attorneys also represent IPAs and physician groups in developing contracts with their participating providers. Our experience includes:
- Capitation contracts
- PBM Contracts
- Pay-for-performance and incentive plan arrangements
- Medicare Advantage and Medicaid managed care contracts
- Multi-product (HMO, PPO, POS) agreements
- Specialty plan contracts (e.g., dental, vision, behavioral health)
- Workers’ compensation network agreements
Our representative projects include:
- Model Contract Development: Represent health plan clients in preparation and updating of comprehensive model capitation and fee-for-service contracts with hospitals, physicians and physician groups to service all lines of business.
- Contract Audit: Represented health plan in a comprehensive audit of hospital and physician group contracts in multiple states to determine ability to support different product lines. Created comprehensive report to summarize the results of the audit.
- Medicare and Medicaid Managed Care Contracting: Represented health plan clients in developing contract forms, updates and amendments to address legal and business issues unique to Medicare and Medicaid plans.
- Incentive Plans: Developed pay-for-performance and physician incentive plans and analyze for compliance with state and federal regulators; developed incentive plans based upon CMS Quality Star Ratings.