Managed Care

Managed care is at the core of how our clients get paid. Current expansion of managed care in Medicare and Medicaid, as well as consolidation of payors, makes understanding managed care more critical than ever.

As many of Hall Render’s clients navigate the myriad of contractual, regulatory and accreditation requirements applicable to arrangements within the health care industry, they rely on the Hall Render team to provide solutions to current issues they are facing and to anticipate any future obstacles.

Hall Render attorneys are experienced advisers who regularly assist a wide range of health care providers, including hospitals, health systems, clinical laboratories, pharmacies and physician practices, 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 payers, 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. 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 payer 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.

If your organization is in need of managed care guidance and practical solutions, please contact Amy Mackin or Julie Lappas to get started.