Our health care attorneys help managed care plans, providers, and employers deal with operational and regulatory issues. We have participated actively in development, licensure and regulatory compliance issues for managed care plans, including multistate managed care plans. We represent managed care plans in the commercial payer and Medicare and Medicaid sectors, including large and small full-service and specialized benefits, including dental, vision care, behavioral healthcare services, chiropractic, and prescription drug benefits, from initial licensure through growth, development and expansion through mergers or acquisitions.
We also represent health systems, hospitals, physician organizations and ancillary service providers with regard to managed care plan contracting and payment issues.
Managed Care Plan Contract Review, Analysis and Negotiations
Hinshaw attorneys have represented managed care plans in developing and negotiating provider contracts with physicians, multispecialty physician groups, IPAs, hospitals and ancillary providers. We have developed provider contracts to address new legal requirements and to support new managed care plan products.
Hinshaw attorneys also assist physician organizations, IPAs and medical groups in developing contracts with their participating providers. Hinshaw also represents health systems, hospitals, physician organizations and ancillary providers in review, analysis and negotiation of managed care plan contracts, and managed care plan contract dispute issues.
Independent Practice Associations and Corporate Formation
Our attorneys have many years of experience and expertise representing the interests of physicians, medical groups and independent practice associations (IPAs). We represent physicians and physician organizations in a variety of contexts; negotiating and enforcing contracts with managed care plans and practice management companies; employment and partnership agreements; mergers, purchases and sales of IPAs and physician practices, and regulatory issues applicable to physician organizations.
Provider Network Development and Maintenance
Hinshaw attorneys have assisted in the creation of virtually all forms of provider networks, including multispecialty and single-specialty physician networks, medical foundations (consisting of hospital affiliates and medical groups), physician hospital organizations (PHOs), academic medical centers and all other types of providers, departmental and combined faculty practice plans, and both hospital-owned and physician equity model management services organizations, as well as ambulatory surgery centers, home health and all other types of outpatient providers. Our experience includes advising on provider/payer reimbursement models, global pricing, bundled payment, and pay for performance; structuring risk-sharing reimbursement methodologies including global capitation and withhold arrangements; counseling on provider contract compliance with applicable state and federal requirements; negotiating payment arrangements between payers and providers; and advising on federal physician incentive plan regulations.
State Licensure and State and Federal Regulation of Managed Care Plans and Insurers
Hinshaw attorneys assist managed care plans in obtaining initial state licensure and provide ongoing advice on the myriad of state and federal regulatory compliance issues to which the industry is subject. This includes drafting applications for licensure and material modifications/amendments, and working on other regulatory compliance issues, including provider network and access issues, marketing activities, benefit design and compliance with mandated benefits, drafting coverage documents, financial solvency, and market conduct examinations. We also assist health plans in complying with applicable federal laws including the federal HMO Act, COBRA continuation of coverage requirements, Medicare secondary payer law, and requirements of the Department of Defense and the Department of Veteran Affairs.
Medicare Advantage Plans
Hinshaw has advised prospective and current Medicare Advantage Plan contractors on program requirements including the annual rate/bid development process, plan design, marketing, enrollment, network access issues, and relationships with health care providers, delegated entities and subcontractors. We have assisted new and existing Medicare Advantage organizations in obtaining state HMO licensure and applying to CMS to obtain a contract to offer general Medicare, Special Needs Plan, Part D plan services and implementing the necessary contracts and agreements. Our attorneys provide advice on ongoing compliance issues and assist Medicare Advantage organizations in responding to and resolving audit findings, including issues related to civil monetary penalties and the False Claims Act.
Medicaid Managed Care
Hinshaw has assisted managed care plans in entering into contracts with state governmental agencies, Two-Plan Model County Local Initiatives and County Mainstream Plans, Geographic Managed Care Programs, and County Organized Health Systems. Our experience includes counseling on the impact of Health Insurance Exchanges; Medicaid Managed Care Waivers (1115, 1915(b), 1915(c), 1915(k), and 1932); Patient-Centered Medical Home and other coordinated care delivery models; preparing bid responses and bid protests; provider network composition and access requirements’ statutory and regulatory requirements for beneficiary access; coverage and payment for out-of-network emergency services; rate and contract negotiations, and regulatory issues.
Program for All-Inclusive Care for the Elderly and Dual-Eligible Integration
Hinshaw attorneys have assisted the largest PACE providers in the country with federal and state legal and regulatory issues that impact the PACE program, including provider applications, expansion applications and waivers; program agreements; administrative requirements; marketing; enrollment/disenrollment; participant rights; benefits/services; service delivery settings; interdisciplinary team assessment and care planning; quality assessment and performance improvement; and grievances and appeals. Hinshaw attorneys also assist health plans and providers in complying with the Centers for Medicare and Medicaid Services and state Medicaid joint regulatory requirements regarding dual eligibles, including provider contract issues; beneficiary protections, regulatory guidance, legislative issues, and waivers.