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
  • Representation of a national healthcare company in an investigation related to allegations of fraudulent risk adjustment coding practices.  Matter involved government disclosure and an analysis of data correction obligations.

    We represented a national healthcare company in an investigation related to allegations of fraudulent risk adjustment coding practices.  Matter involved...
    Read More
  • Representation of a Medicare Advantage Organization in an investigation related to data-driven coding anomalies and practices detected at a large contracted provider group.

    We represented a Medicare Advantage Organization in an investigation related to data-driven coding anomalies and practices detected at a large...
    Read More
  • Representation of a Medicare Advantage Organization and its wholly-owned provider group in an internal investigation related to allegations of improper coding practices, hostile work environment, and non-compliance with Medicare requirements.

    We represented a Medicare Advantage Organization and its wholly-owned provider group in an internal investigation related to allegations of improper...
    Read More
  • Representation of a Fortune 50 healthcare company in conducting oversight of network provider marketing practices and compliance with Medicare marketing regulations.

    We represented a Fortune 50 healthcare company in conducting oversight of network provider marketing practices and compliance with Medicare marketing...
    Read More
  • Representation of a Medicare Advantage plan in multiple internal investigations related to its grievance and appeal procedures.

    We represented a Medicare Advantage plan in multiple internal investigations related to its grievance and appeal procedures.
    Read More
  • Representation of a large national healthcare company in its defense of a FCA qui tam involving its wholly-owned Pharmacy Benefit Manager.  After extensive negotiation, DOJ declined to intervene in the matter.  The relator pursued the case independently, which resulted in a favorable resolution to our client.

    We represented a large national healthcare company in its defense of a FCA qui tam involving its wholly-owned Pharmacy Benefit...
    Read More
  • Representation of a national managed care organization in an internal review of potentially improper home health and hospice discharge protocols.

    We represented a national managed care organization in an internal review of potentially improper home health and hospice discharge protocols.
    Read More
  • Representation of a managed care organization in a review of whistleblower allegations related to the post-acquisition integration of a specialty pharmacy.  The matter involved an assessment of risk specific to data privacy obligations.

    We represented a managed care organization in a review of whistleblower allegations related to the post-acquisition integration of a specialty...
    Read More
  • Representation of a Fortune 50 healthcare company in its response to a third-party grand jury subpoena.

    We represented a Fortune 50 healthcare company in its response to a third-party grand jury subpoena.
    Read More
  • Representation of a Fortune 50 healthcare company in its response to a third-party grand jury subpoena.

    We represented a Fortune 50 healthcare company in its response to a third-party grand jury subpoena.
    Read More
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
Member
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