Managed Care

As managed care continues to grow and evolve, our clients remain focused on delivering high-quality and cost-effective healthcare in an environment that is subject to heightened scrutiny and enforcement. The attorneys in our multi-disciplinary Managed Care practice have the knowledge and experience necessary to advise clients on the full spectrum of business, legal, and compliance issues impacting the industry.  We partner with our clients to navigate this complex regulatory environment and to mitigate risk.

Our attorneys bring federal agency and private defense experience to enforcement and litigation matters involving, for example, the False Claims Act (FCA), Anti-Kickback Statute (AKS), Stark Law, administration of the Part D drug benefit, and Medicare Advantage risk adjustment. We advise companies on internal and governmental investigations involving the U.S. Department of Justice, Centers for Medicare and Medicaid Services, Office of Inspector General for U.S. Department of Health and Human Services, and others.

Our practice also draws on the firm’s deep bench of healthcare regulatory and reimbursement attorneys for matters important to managed care organizations. We provide compliance counseling focused on holistic assessments of enterprise risk to develop mitigation strategies. In privacy and cybersecurity, we assess risks and offer program design or enhancements as well as advising on data breach response, including conducting investigations and developing notifications for affected individuals. We also advise on strategic transactions including mergers and acquisitions and joint ventures, as well as contract negotiations, bankruptcy and restructuring, and antitrust considerations. We assist clients with responding to governmental inquiries, including subpoenas, and self-disclosures to federal and state regulatory agencies.

We counsel a variety of clients, including:

  • Health plans
  • Pharmacy benefit managers
  • Pharmacies
  • At-risk providers
  • Electronic health record organizations
  • Other vendors interacting with plans and providers in the managed care space

Our interdisciplinary team has significant experience advising clients on issues and laws relevant to the industry, including:

Regulatory & Compliance

  • Medicare/Medicaid compliance, including risk adjustment data validation (RADV) audits
  • Compliance program assessment, development and implementation
  • Provider-fraud detection and remediation
  • Quality metrics, including HEDIS/STARs reporting
  • Management services organization (MSO) relationships
  • Overpayment Rule Telehealth
  • Affordable Care Act
  • Medical loss ratio
  • No Surprises Act

Investigations & Disputes

  • Medicare Advantage risk adjustment
  • Antitrust
  • Benefits and coverage
  • Labor and employment
  • IT vendor disputes
  • Provider disputes

Privacy & Cybersecurity

  • Cybersecurity risk assessment, program design, and enhancement
  • Data breach response, including investigation and notification
  • Creation of incident response plans
  • Analysis of adequacy of protections for data on cloud
  • Review of data-sharing arrangements involving PHI and other regulated health data
  • Health information exchanges
  • HIPAA and state privacy laws

 Transactions

  • Mergers, acquisitions, joint ventures, and other transactions
  • Deal due diligence
  • Contract negotiations
  • Antitrust considerations
  • Bankruptcy and restructuring
  • Tax structuring
  • We represented a global for-profit health insurance company with more than 20 million members in False Claims Act (FCA) litigation in federal court in the Northern District of Illinois.

    We represented a global for-profit health insurance company with more than 20 million members in False Claims Act (FCA) litigation...
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    Client Type: Private Company
  • Representation of LogistiCare in its $80 million acquisition of National MedTrans, a single source Non-Emergency Medical Transportation (NEMT) benefit management company focused on delivering services to managed care organizations and governmental entities throughout the United States, as well as the extension of its revolving credit facilities from $200 million to $225 million

    We represented LogistiCare in its $80 million acquisition of National MedTrans, a single source Non-Emergency Medical Transportation (NEMT) benefit management...
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    Client Type: Private Company
  • Representation of WellCare Health Plans, Inc., a government-focused managed care provider, in its merger with Centene Corporation (NYSE: CNC) for $17.3 billion

    We represented WellCare Health Plans, Inc. in its merger with Centene Corporation (NYSE: CNC) for $17.3 billion. The combined company...
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    Client Type: Public Company
  • Represented WellCare Health Plans, Inc. (NYSE: WCG) in its definitive agreement to acquire Meridian.

    We represented WellCare Health Plans, Inc. (NYSE: WCG) in its definitive agreement to acquire Meridian for $2.5 billion in cash. Meridian is a...
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    Client Type: Public Company
  • Obtained summary judgment on behalf of a group of 21 Tennessee physicians in federal litigation in Nashville challenging a regulation from Centers for Medicare & Medicaid Services

    We obtained summary judgment on behalf of a group of 21 Tennessee physicians in federal litigation in Nashville challenging a...
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    Client Type: Individual
  • Represented WellCare Health Plans in its definitive agreement to acquire Care1st Health Plan

    We represented WellCare Health Plans in its acquisition of Care1st Health Plan Arizona, Inc. and ONECare by Care1st Health Plan...
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    Client Type: Public Company
  • Represented WellCare (NYSE: WCG) in its acquisition of Medicaid Assets of Phoenix Health Plan

    We represented WellCare Health Plans, Inc. (NYSE: WCG) in its acquisition of Medicaid assets of Phoenix Health Plan (PHP) in...
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    Client Type: Public Company
  • Provided legal counsel to WellCare in its acquisition of Universal American Corp.

    We represented WellCare Health Plans, Inc. (NYSE: WCG) in its acquisition of Universal American Corp. (NYSE: UAM). The transaction is...
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    Client Type: Public Company
  • Representation of Medicare Advantage service provider in qui tam alleging that defendants caused inflation of risk adjustment scores. U.S. ex rel. Ramsey v. Censeo Health, L.L.C., No. 3:14-cv-118 (N.D. Tex.)

    We represented Medicare Advantage service provider in qui tam alleging that defendants caused the inflation of risk adjustment scores. U.S....
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  • Serving as lead counsel for Air Methods Corporation in seven putative class actions filed in federal district courts around the country in which patients are challenging the reasonableness of the company’s charges for emergency air ambulance services

    We are lead counsel for Air Methods Corporation in seven putative class actions filed in federal district courts around the...
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    Client Type: Public Company
Nicholas M. Bessette
Associate
David R. Esquivel
Pro Bono Member
Lindsey Brown Fetzer
Member
Jeff H. Gibson
Member
Brian R. Iverson
Member
Wesley McCulloch
Associate
Sara K. Morgan
Associate
Dawn Perez-Slavinski
Associate
Lisa S. Rivera
Member
Molly K. Ruberg
Member
Angelique M. Salib
Associate
Julia Tamulis
Member
T. Stephen C. Taylor
Member
Ryan D. Thomas
Member
Meredith Mallard Thompson
Counsel
Price W. Wilson
Member
Roy Wyman
Member
Virginia Maynard Yetter
Associate
Abby Yi
Associate

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