While managed care at its best helps to optimize patient care while minimizing costs, it can also create a labyrinth of regulatory and contractual issues for providers and managed care organizations (MCOs) alike. Today, virtually every government health care program or private insurance plan incorporates elements of managed care, negotiating contracts with providers to care for members at a reduced cost. Thus, for most healthcare providers, involvement in Medicare Advantage (MA) and other MCOs is a complicated necessity.
When trying to maintain revenue sources, reduce expenditures, and cope with budget constraints, mistakes that result in changes or denials by payors can be significant. Likewise, health insurance companies and managed care organizations must address an ever-changing and growing list of legal issues ranging from regulatory compliance to licensure and transactional matters, ensuring their own compliance to avoid liability. Because Jackson Walker represents both plans and providers, we have unique insight into market dynamics, the methodology behind payments, and the effect of regulations on both sides of the table.
Our attorneys have considerable experience developing and advising physician hospital organizations, preferred provider organizations, independent practice associations, management service organizations, third-party administrators, self-insured plans, and other integrated delivery systems on developing successful, timely, and cost-effective organizational responses to managed care operational and regulatory issues.
We work proactively with our plan clients as they navigate regulatory hurdles. We ensure they understand the complex legal issues surrounding risk assumption payment methodologies and provider selection, licensure, and accreditation issues, and we assist in the development of new and innovative payment structures.
Provider clients want predictability and clarity. We ensure they are well-informed regarding the complex and continually changing regulations governing plans and that their contractual interests are protected. Managed care contracts present complex liability and risk issues that are impacted by both federal and state regulatory considerations. Successful, predictable contracting demands experienced counsel. We have negotiated, drafted, and defended contracts in all phases of the healthcare system, from creation of the initial admission document to final audit of the claim. We also advise on operational, credentialing, and medical staff issues that can affect plan eligibility.
When mistakes are made, we interact on our clients’ behalf with regulators through all stages of an allegation, from initial response to litigation and appeal.
Mary Emma Karam was appointed by the Texas Attorney General to serve a term as Special Outside Counsel to the Office of the Attorney General for the State of Texas for consultation in healthcare/managed care matters for the state.
- Obtained reinstatement of managed care contracts terminated by insurance plans, saving over $300 million/year in revenue.
- Enhanced revenue by improving legal language in managed care contracts that allow denial of claims.
- Revised legal documents from admission to audit and increased claims payment and revenue for hospital.
- Negotiated managed care contracts for use by hospital system in 47 states.
- Represented hospital in acquisition of a Texas joint stock insurance company.
- Provided legal work to sell a PPO Network
- Assisted HMO in applying for licensure in all 50 states.
- Admission documents
- Advice on managed care contracting and strategy
- Network contracts
- Payor issues and claims issues advice and strategy
- Audit policies
- Revenue cycle adjustments to enhance payment of claims
- Records policies
- Formation and representation of Clinically Integrated Networks
- Formation and representation of Accountable Care Organizations
- Bundled payment agreements
- HMO certificates of authority
- Value-based purchasing
- Drafting and negotiation of managed care contracts
- Advice on compliance with state laws
- Advice on Medicaid statutory, regulatory, and contractual requirements
- Representation before regulatory commissions including the Texas Board of Insurance
- Medicaid Fair Hearings
- Contracting with the Agency for Health Care Administration for Medicaid coverage
- Review of insurance policies and HMO contracts
- Recovery of underpayments from managed care companies, including Medicare Advantage
- Advice on compliance issues arising from provider relationships
- Counsel on provider contracting and terminations, and development of utilization review and quality assurance policies
- Termination defense and reinstatement under managed care plans
- Advice on creation of subsidiaries and joint ventures for MA plans and providers
- Drafting and negotiation of payor-provider agreements involving risk-sharing, pay for performance, and capitation in compliance with MA requirements
- Drafting and negotiation of plan contracts, MA network agreements, and physician and facility participation in MA plans
- Medicare Part C and D advice on data validation reporting requirements, Chapter 9 compliance program requirements, and Chapter 12 claims processing requirements