Managed Care

Our Experience

  • Regulatory
    • FWA Counseling
      • Counsel national MAO on the application of the managed care safe harbors to certain arrangements where an affiliate was offering below fair market value administrative services to both the MAO and unrelated health plans
      • Counsel national homecare provider on value-based agreement with national MAO
      • Counsel regional MAO on AKS issues relating to physician marketing costs associated to a co-branded plan
      • Counsel MAOs, national retail pharmacy chains and PBM clients with affiliated pharmacies on the development and implementation of member rewards programs and the offer of such programs to Medicare Part D plan members
      • Counsel national MAO and related-party provider group on AKS, CMPL and Medicare Rewards & Incentive rules
      • Develop compliance programs, code of conduct, employee training, and policies and procedures addressing fraud, waste, and abuse for multiple MCO clients
      • Counsel plans and FDRs in the detection and reporting of overpayments and in navigating the intricacies of voluntary self-disclosure of non-compliance
      • Counsel an MAO on the Stark implications of providers offering lower co-payments for prescriptions filled at a related pharmacy
      • Counsel Medicaid Managed Care client on adoption and implementation of patient/member rewards, loyalty and coupon programs application to Medicaid Managed Care members
    • Risk Adjustment
      • Represent national and regional MAOs in responding to multiple CMS and OIG risk adjustment validation audits
      • Advise large plan-affiliated provider group on issues relating to medical record addenda, comprehensive wellness visits, and attestations used to cure medical record errors during RADV audits
      • Conduct compliance assessments for multiple regional MAOs focusing on design and structure of risk adjustment departments
      • Represent national risk adjustment vendor on issues relating to compliance, risk adjustment service offerings, pricing, and client contracting
      • Counsel regional MAO on audit best practices relating to risk adjustment
      • Represent national MAO in negotiating its Corporate Integrity Agreement with HHS-OIG relating to risk adjustment activities
      • Counsel regional managed care organization regarding ACA risk adjustment requirements
    • Star Ratings
      • Advise regional health plan regarding Star Rating implications for potential transactions and joint ventures
      • Advise national health plans regarding Part D Star Ratings implications of merger of two Part D plan sponsors
      • Advise national MAO and affiliates on implications of transaction-target’s Star Ratings and implications of Board overlap
      • Negotiate and draft agreement between a regional MAO and a vendor engaged to help improve performance relating to specific Part D HEDIS measures and MTM
      • Appeal Star Ratings for historic 4-Star rated plan with issue concerning ODAG and CDAG
      • Appeal Star Ratings for MAO in its third year of operation (therefore no longer considered a “new MA plan”) receiving its first Star Rating
      • Advise regional MAO on Star Rating issues likely to result from the PHE COVID Interim Final Rules announced in April and August 2020
    • Medicare Contract Applications and Service Area Expansion
      • Represent national MAO in the restructuring of its Medicare business, requiring multiple SAEs and novations
      • Successfully represent regional MAO in appealing CMS’s Denial of two SAEs
      • Successfully appeal CMS’s Denial of a proposed Part D plan sponsor’s application for its initial Part D contract and EGWP offering
      • Successfully appeal CMS’s Denial of a proposed MAO’s application for its initial contract
      • Advise national Part D plan sponsor on contracting and pricing requirements for a service area expansion application
    • Medicaid Managed Care RFP Assistance and Bid Protests
      • Advise a Medicaid Managed Care Organization (“MMCO”) in preparing its response to a Request for Proposals for the State’s managed care program, including providing legal guidance on RFP requirements and reviewing full RFP response for deficiencies.
      • Advise a national Medicaid Managed Dental Plan through multiple state Medicaid procurements, including advising on pros and cons of bid protests.
      • On behalf of an MMCO, successfully engaged in a bid protest challenging a state’s RFP scoring process and once successful, assisted MMCO client in winning the contract to offer a Medicaid Managed Care plan within the state
    • Medicare Bid Rules and regulations including Related Party Disclosures
      • Provide support for a major Part D plan in an OIG audit of its estimation of rebates in its bids, including preparation of a white paper to OIG; interaction with CMS for submission of the OIG findings; and ultimately succeeding in having CMS not pursue any adjustments or penalties
      • Advise national provider with joint ventures with MAOs regarding the implications of its related party status for purposes of MA bids and help provider prove that the contracted pricing was comparable with its pricing for unrelated parties and assist provider in providing its unrelated party contracts to CMS, rather than the MAO
      • Advise national MAO on implications for different related-party arrangements spanning non-medical expenses and medical expenses in MA and drug expenses in Part D
      • Actively engage with CMS regarding level of pricing detail needed to be included in agreements that support the actuarial assumptions of an annual bid and how such agreements may be viewed by bid auditors
      • Advise national Part D plan sponsor in regards to related party bidding implications of its ownership of a PBM
      • Advise regional MAO regarding the bid implications of its strategy regarding provider-practice acquisition and friendly-PC arrangements
      • Advise national MAO regarding the bid implications of the administrative services provided by its related-party pharmacies
    • Medical Loss Ratio
      • Counsel national MAO on engagement with CMS regarding errors in MLR reporting
      • Counsel managed care organization regarding MLR reporting for ACA exchange
      • Counsel multiple MAOs regarding related-party arrangements and MLR
      • Advise multiple value-based care organizations regarding implications of their pricing for plan reported MLR
      • Advise national MAO on MLR implications of potential acquisitions
    • Direct & Indirect Remuneration
      • Counsel national MAOs on the DIR implications of the pharmacy pricing established between the plan, PBM and related-party pharmacy
      • Assist several MAOs in completing DIR reports and appropriately categorizing various streams of value
      • Counsel Part D plans on the developments regarding point-of-sale rebates and negotiated price
      • Counsel regional PBM regarding potential FWA implications of improperly disclosing to its Part D plan clients the percentage of rebates retained by an upstream aggregator
      • Advise national PBM on the implications of risk sharing arrangements in DIR reporting
      • Advise rebate aggregators on client reporting obligations as a result of Part D DIR reporting requirements
    • Sales and Marketing Compliance
      • Counsel national MAO on structure of commissions and administrative fee arrangements
      • Counsel multiple MAOs on CMS 2025 rules for broker/agent arrangements and implications of on going litigation regarding such rules
      • Counsel national TPMO regarding disclosures and compliance requirements in Medicare and ACA
      • Counsel national MAO on allowable rewards and incentive programs for members
      • Advise regional MAO on forming and marketing co-branded plans
      • Advise national MAO on sales commission structures relevant to EGWPs and brokers
      • Counseling MA and Part D plans on the Medicare Marketing Guidelines, including co-branding issues and explanation of benefits requirements
    • Product/Benefit Design
      • Engage with CMS regarding MAOs offering hospital-at-home services and focus on bidding implications and potential reimbursement for such benefits
      • Advise MAOs and national UM/PA vendor regarding compliance with MA UM rules relating to prior authorization and “fully established”
      • Advise national MAO regarding allowable benefit designs and utilization management controls that can be placed on Medicare Part B drugs
      • Advise national MAO regarding supplemental benefits and value-added services that relate to fitness
      • Advise MMCOs and PBMs on issues related to individual State Medicaid and MMCO requirements regarding drug formularies, Preferred Drug Lists, prior authorization and e-PA, coverage of OTC drugs
      • Advise MMCO regarding when certain products should be provided under a Medicaid Managed Care benefit versus a dual eligible plan benefit
      • Counsel growing supplement benefit vendor regarding the structure of its offering, responding to managed care RFPs, and contracting with managed care organizations
      • Counsel multiple organizations regarding integrated benefit offerings relating to pharmacy pricing
    • Employer/Union Group Offerings (EGWP)
      • Assist regional and national MAOs with establishing an EGWP offering by drafting policies and procedures and client contract templates
      • Assist regional MAO with establishing an EGWP for its employees
      • Advise national MAO on EGWP MLR issues associated with OHI
      • Assist a PBM with establishing an EGWP offering by successfully applying for and contracting with CMS, drafting policies and procedures, and negotiating and contracting with EGWP clients
      • Assist Part D plan sponsor EGWPs through multiple RFPs opposite state agencies/associations
  • Transactions
    • Represent The Cigna Group in the sale of its Medicare business to HCSC
    • On behalf of a supplemental benefit vendor, diligence multiple strategic acquisition targets
    • On behalf of a national MAO, diligence national advanced primary care provider group
    • Support a national MAO it the sale of its MMP business
    • On behalf of a national MAO, diligence national Part D plan sponsor
    • On behalf of a national MAO, diligence regional MAO and identify inappropriate supplemental benefits offered by the regional MAO and analyze potential regulatory and fraud and abuse risks
    • On behalf of a PE firm, diligence a FDR target that assists MAOs administer supplemental benefits, including OTC benefits
    • Diligence multiple national risk adjustment vendors on behalf of a PE firm
    • For a broader list of transactional experience, please see Health Care Transactions
  • Investigations and Litigation
    • Partner with litigation counsel to support a national MAO in its responses to and settlement of federal False Claims Act risk adjustment investigation
    • Represent regional MAO in a federal False Claims Act risk adjustment investigation and negotiate settlement
    • Represent national MAO and providers groups in responding to the DOJ on a far-reaching subpoena relating to risk adjustment practices
    • Represent national UM/PA vendor in declined qui tam case
    • Represent national MAO in contract disputes with hospitals regarding 340B
    • Represent TRICARE managed care plans in False Claims Act suit relating to alleged overpayments
    • Represent national Part D plan sponsors in responding to CIDs and the ultimate dismissal of a declined FCA qui tam case U.S. ex rel. Borzilleri v. AbbVie Inc., et al.in SDNY and U.S. ex rel. Borzilleri v.Bayer Healthcare Parms., Inc., et al DRI (Dismissals upheld by the Second Circuit in 2020 and the First Circuit in 2022) relating to Part D DIR reporting
    • For a broader list of investigations and litigation experience, please see Health Care Enforcement Defense