Managed Care
Powering the Future of Managed Care
Managed care is one of the most highly regulated and operationally complex sectors in the US health care system – impacting nearly every stakeholder in the industry. Our team brings decades of experience delivering strategic, day-to-day legal and regulatory counsel to managed care organizations and other third party payors, their vendors, and large provider organizations.
Share Awards
Chambers USA
Ranked across multiple practice areas and industries including Corporate/M&A, Healthcare, and Technology, among others
Modern Healthcare
Recognized as one of the largest health care law firms in the US
Legal 500 United States
Recommended for Life Sciences
Our Approach
Clients rely on us to guide them through their most mission-critical matters- from complex transactions and high-stakes contract matters to state and federal government investigations, and litigation. With a deep understanding of both the regulatory landscape and the business imperatives driving managed care organizations, we regularly engage with federal agencies, including the Centers for Medicare & Medicaid Services and the Office of Inspector General for the Department of Health and Human Services, and state departments of insurance and attorneys general on behalf of our clients.
Our team provides strategic counsel on the full spectrum of managed care programs including:
- Medicare Advantage
- Special Needs Plans
- Medicare Prescription Drug Plans
- Medicaid Managed Care Plans
- EGWPs
- ACA Exchange Plans
- Employer Plans
- FEHBP
- TRICARE
Our clients who operate in these areas or provide services to entities that do benefit from our advice in the following areas:
- Regulatory Advice
- Medicare Advantage and Part D Bidding and Related Party Matters
- Medicaid Managed Care Contracting – contract interpretation, responses to state RFPs, and RFP award challenges
- Financial Reporting - Medical Loss Ratio (MLR) and Direct & Indirect Remuneration (DIR)
- Risk Adjustment – internal and external audits, compliance processes, government investigations, coding services
- Benefit Design – Uniformity, Supplemental Benefits, Utilization Review/Prior Authorizations, Formulary Requirements
- Communication Rules – Marketing and Agent/Broker Compensation
- Medicare Contracting – Applications, Services Area Expansions, Consolidations, Audits, Novations, Star Ratings, etc.
- Provider and Pharmacy Networks – compensation, PIP rules, risk arrangements, adequacy requirements
- Compliance Programs
- Fraud & Abuse counseling
- Complex Contracting
- Value-Based Care
- PBM Contracting
- Agent/Broker Arrangements
- Risk Adjustment Coding Engagement
- Advanced Primary Care and Wrap Around Contracting
- Transactions
- Regulatory due diligence
- Transaction structuring
- Strategic mergers and acquisitions
- Private Equity acquisitions
- Spin Offs
- Application and impact of state transaction review laws
- Federal and State Government Investigations/enforcement actions
- Commercial Litigation
- Arbitration
- Contract Disputes
- 340B Reimbursement
- Managed Care Organizations
- Third Party Administrators
- Supplemental Benefit Vendor
- Risk Adjustment Coding Vendors
- Utilization Review Vendors
- Pharmacy Benefit Managers
- Third Party Marketing Organizations
- Value-Based Care Organizations
