"Managed Care" describes any health care delivery system in which a party other than the physician or the patient influences both the medical and financial aspects of a patient's care. Legal and business issues relating to Managed Care and MCOs are complex and constantly evolving, requiring sophisticated advisers who can quickly and accurately respond to changing client needs.
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Negotiated major managed care contracts with most national plans on behalf of hospital systems, physician MCOs, alternative health care delivery organizations and other providers.
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Developed managed care provider and payor contracts for health plans and MCOs.
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Represented ancillary services provider in the development of a national contracting network.
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Represented ten public hospital systems in structuring and obtaining regulatory approval for a provider-owned health maintenance organization (HMO).
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Implemented 50 multiple provider networks by developing and implementing network access agreements, payor agreements and provider participation agreements for hospitals, physicians, ancillary providers and network access agreements for physician MCOs.
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Assessed operational deficiencies, provided turnaround assistance and developed measures to improve the bottom line as it related to compensation for payor services.
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Developed and implemented national credentialing plans and utilization management plans for national health plans/carriers and dental plans/carriers.
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Developed and implemented performance-based compensation programs for national health plans, physician group practices and IPAs.
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Participated in and implemented the start-up and licensing of new HMOs and preferred provider organizations (PPOs).
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Negotiated and facilitated private sector payor and government sector payor (Medicare, Medicaid and CHAMPUS) contracts with managed care plans.
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Developed and implemented regulatory compliance plans for billing and payor companies, hospitals, large physician groups and other health care providers.
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Drafted model risk sharing agreements for national HMOs and assisted in having them approved by several state Departments of Commerce and Insurance.
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Assisted MCO nationally with devising and implementing provider selection and deselection criteria and processes that comply with federal and state laws and regulations and incorporate the accreditation standards of NCQA, JCAHO and URAC.
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Advised troubled HMOs during state insurance department administrative supervision, rehabilitation and liquidation procedures.