Overview
As health care delivery evolves to include risk contracting, managed care reform, and pay-for-performance, hospitals and physician group need to stay on top of changing requirements. Health care providers seeking efficient administration and growth of their managed care arrangements turn to Ropes & Gray lawyers for in-depth information and guidance.
Since working on the formation of the first HMO in New England in 1969, we have assisted clients in the creation, management, and growth of managed care plans and provider networks for managed care contracting. We advise hospitals, health systems, academic medical centers, physician-hospital organizations, physician practice groups, independent practice associations (IPA), and other health care providers in designing and participating in a full range of managed care transactions.
We help clients with:
- Creation of optimal managed care contracting arrangements
- Advice about compliance with federal and state laws, regulatory and reimbursement issues and fraud and abuse
- Formation of physician incentive plans, including gain-sharing requirements
- Understanding prompt payment claims processing requirements and provider termination rights under ERISA and state managed care laws
Our lawyers are well versed in antitrust considerations related to joint contracting, including the requisite needs for clinical and/or economic integration. We analyze tax-exempt considerations and anti-kick back/Stark implications of various fund flow models. We also represent hospitals and other health care providers in dispute resolution issues related to managed care contracts.
We work on:
- Interpretation of managed care contract provisions
- Resolution of antitrust, tax, bankruptcy and receivership matters
- Negotiation of all forms of contracts, mergers and acquisitions, and restructurings for managed care providers
Experience & Clients
Our health care lawyers have wide ranging experience in the creation of managed care contract arrangements and resolution of any disputes arising out of those arrangements. We are thoroughly familiar with federal and state law regarding benefit provisions and payor rules and have represented a variety of health care providers.
Our recent experience includes:
- Representation of a managed care organization in a dispute about compensation under a participation agreement with an acute care hospital.
- Acting as outside counsel to a hospital member of a city-wide network to conduct and respond to discovery, identify and prepare witnesses on contract interpretation issues and prepare for and participate in hearings.
- Assistance with a contract interpretation dispute regarding provider expenses not included in the formula used to calculate the provider’s capitation payment.
- Interpretation of coordination of benefit provisions and Medicare secondary payor rules.
- Distinguishing what constitutes “cause” and the enforceability of termination without cause provisions under state law.
- Interpretation of payor obligations to pay claims even if billed outside of the time limits and of payor obligations to make a provider whole for breaches of responsible party in administrative services only (ASO) agreements.
- Enforceability of contract provisions in bankruptcy and insolvency situations.
- Preemption of state law and enforcement initiatives by Medicare Advantage laws.
- Interpretation of prompt pay and utilization review laws.
- Negotiation of “carve-out” contracts between disease management providers and health plans.
We represent hospitals, health care networks and other managed care providers. We have particular depth of experience in the northeast region of the United States.
Recent clients include:
- Blue Cross and Blue Shield of Rhode Island
- Boston Medical Center HealthNet
- Comprehensive Care Management
- Delta Dental
- Express Scripts, Inc.
- Fisherman's Partnership Health Plan
- Group Health Cooperative
- Harvard Pilgrim Health Care
- Healthfirst, Inc.
- Health New England
- Humana, Inc.
- Independence Blue Cross/Keystone Health Plan East
- Network Health
- Tufts Health Plan
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