Provider-Sponsored Health Plans

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Provider-sponsored health plans (“PSHPs”) have become increasingly part of a health system’s strategic plan as providers strive to coordinate high-quality care, tailor health care for the community, 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...Read More

Provider-sponsored health plans ("PSHPs") have become increasingly part of a health system’s strategic plan as providers strive to coordinate high-quality care, tailor health care for the community, 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 in assessing whether they have the capabilities to develop a PSHP, such as evaluating whether the health system has sufficient resources for start-up costs, the financial ability to take on risk, and the risk management experience and care coordination 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 federal and state insurance and other laws and regulations. For established health plans, our attorneys have worked with PSHPs on corporate, regulatory, network and general matters.

We have assisted PSHP clients with an array of services, such as:

  • Establishing networks in furtherance of plan offerings;
  • Operating credentialing and compliance programs;
  • Responding to regulatory inquiries and audits;
  • Creating joint ventures;
  • Developing new product offerings;
  • Reviewing Medicare Advantage compliance programs;
  • Understanding and implementing changes to state and federal law;
  • Drafting participation and network 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 counsel PHSP owners (and potential owners) on the acquisition and sale of health plans and the regulatory and operational issues that arise with these transactions.

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