With mounting pressure to control health care costs, the techniques and strategies of managed care - once confined to health maintenance organizations - have become ubiquitous. Now virtually every government health care program and private insurance plan incorporates elements of managed care, negotiating contracts with providers to care for members at reduced costs. Managed Care Organizations (MCOs) now also take many forms, including Health Maintenance Organizations (HMOs), Preferred Provider Networks (PPOs), Independent Practice Associations (IPAs) and Integrated Delivery Systems (IDS).
Managed care is increasingly one of the most heavily regulated sectors of the health care industry. And every state has its own rules. As a result, the legal and business issues that affect managed care and MCOs are complex and constantly evolving, requiring sophisticated advisers who can respond quickly and adeptly to a client’s changing needs. Baker Donelson's managed care attorneys have years of experience, both as in-house counsel for large MCOs, including HMOs, and as outside legal advisers.
We know the law. And we know the business of managed care.
Contract Development and Negotiation
Managed care contracts present complex issues of responsibility, liability and risk, with overlapping federal and state laws and regulations. They demand experienced counsel.
As advisors to private payors and various types of regional and national MCOs, Baker Donelson attorneys have experience developing and negotiating a wide range of agreements, including hospital system contracts with national insurers and contracts for health plans and physician groups, alternative health care delivery organizations and newly formed MCOs.
Beyond contracts, MCOs must adhere to multiple layers of complicated regulation, with every state having its own robust set of compliance requirements that organizations must meet daily. Throughout our health care practice, Baker Donelson’s core philosophy is to help clients avoid trouble by working proactively to navigate regulatory hurdles. Our attorneys have helped public hospital systems, physician groups and insurance companies, among others, develop and implement regulatory compliance plans.
We also help when things go wrong, working with organizations to assess operational deficiencies, providing turnaround assistance, developing rehabilitation plans and advising troubled MCOs in administrative proceedings.
Development and Structuring
Baker Donelson attorneys have a broad range of experience helping to develop and structure MCOs, whether the situation involves one MCO absorbing another or a public hospital system structuring and obtaining regulatory approval for a new provider-owned HMO. The Firm's broad health care experience also enables us to help clients with matters such as provider selection criteria and compliance with the accreditation standards of organizations like the National Committee for Quality Assurance (NCQA) and The Joint Commission.
Our objective is to help clients make sure the MCO is structured to meet their business, operational and compliance needs.