Managed Care

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Hall Render attorneys are experienced advisers who regularly assist a wide range of health care providers in a full array of services related to managed care relationships, reimbursement and network participation. We routinely assist in the preparation and negotiation of a wide variety of participation agreements between providers and payors, including commercial health insurers, self-insured...Read More

Hall Render attorneys are experienced advisers who regularly assist a wide range of health care providers in a full array of services related to managed care relationships, reimbursement and network participation. We routinely assist in the preparation and negotiation of a wide variety of participation agreements between providers and payors, including commercial health insurers, self-insured plans, Medicare Advantage and Medicaid plans, accountable care organizations ("ACOs"), pharmacy benefit managers and government managed care programs for federal employees and military members. We serve as a readily available and reliable resource for providers such as hospitals, health systems, clinical laboratories, pharmacies and physician practices in order to ensure compliance with the myriad of contractual, regulatory and accreditation requirements applicable to these arrangements. Our attorneys are also experienced in counseling health care providers and vertically integrated organizations on the regulatory and transactional issues related to establishing provider-sponsored health plans and clinically integrated networks.

Our services include the negotiation and interpretation of managed care and network participation contracts; assistance with dispute resolution, arbitration and litigation of payor disputes; guidance on the statutory and regulatory requirements of Medicare Advantage, the Medicare prescription drug benefit ("Part D") and Medicaid managed care programs in numerous states; transitioning to out-of-network status; developing a strategy for responding to out-of-network payment issues and cost-plus pricing; and addressing issues concerning financial assistance programs and balance billing. We are also proficient in related areas that impact managed care arrangements, including risk-based reimbursement methodologies such as capitation, pay for performance, shared savings and global and bundled payment arrangements; value-based reimbursement; clinical integration strategies; and related compliance issues. Our attorneys regularly assist clients with ongoing operational issues and questions concerning ACO governance, the Medicare Shared Savings Program, participant relations and commercial contracting. We have formed rural ACOs as well as new and emerging accountable care entities, assisting with the regulatory and practical complexities that accompany financial, operational and clinical integration. We have extensive experience in developing and forming complex and innovative provider entities and arrangements for the delivery and financing of cost-effective, quality care. This experience provides us with a thorough understanding of provider alignment performance metrics and the development of provider incentive programs.

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Areas of Focus

  • Network Participation and Payor Arrangements
  • Accountable Care Organizations (ACOs)
  • Provider-Sponsored Health Plans
  • Point of Service (POS)
  • Preferred Provider Organizations (PPOs)
  • Medicare Advantage and Medicare Part D
  • Medicaid Managed Care
  • Pharmacy Benefit Management
  • Clinical Integration
  • Shared Savings and Provider Risk