Provider-Sponsored Health Plans

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Provider-sponsored health plans (“PSHPs”) have become more common as providers strive to coordinate high-quality care, tailor health care for the local population, manage risk and engage in population health management. These goals are essential in an age where payment models are expected to change and efficiency, quality, risk management and patient satisfaction are of paramount...Read More

Provider-sponsored health plans ("PSHPs") have become more common as providers strive to coordinate high-quality care, tailor health care for the local population, manage risk and engage in population health management. These goals are essential in an age where payment models are expected to change and efficiency, quality, risk management and patient satisfaction are of paramount importance.

Our attorneys have assisted hospital and health system clients assess whether they have the capabilities to develop a PSHP, such as assessing whether the health system has sufficient resources for start-up costs, the financial ability to take on risk and the risk management experience and infrastructure necessary to manage membership and achieve sustainability. We can help health systems to develop an effective, practical and comprehensive work plan, obtain all necessary licenses and governmental approvals, consider capital needs and generally bring a PSHP to fruition in compliance with applicable state and federal insurance and other laws and regulations.

For established health plans, our attorneys have represented provider-sponsored health plans on corporate, regulatory and general matters in both outside counsel and general counsel roles. We have assisted health plan clients with credentialing and compliance programs, responding to regulatory inquiries and audits, developing policy language, developing new product offerings, reviewing Medicare Advantage compliance programs, researching and implementing changes to state and federal law, drafting provider agreements, advising on tax-related structuring and other organizational issues and responding to issues that arise daily in the health insurance industry. In addition, we routinely counsel and advise health system owners on the purchase and sale of health plans and the regulatory and operational issues that arise with these transactions.

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