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Industry Overview

Overview

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), Third Party Administrators (TPAs), 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. Litigation involving MCOs is also on the rise.  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.

Managed Care Litigation

Baker Donelson attorneys defend MCOs across the nation in disputes with in-network and out-of-network providers, as well as defending denial of benefit lawsuits by members.  Lawsuits between MCOs and in-network providers can involve a multitude of complex issues driven by the contract. Litigation with out-of-network providers is increasingly becoming complex and requires special expertise to defend.  Baker Donelson’s expertise runs that deep. 

Regulatory Compliance

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. Moreover, some of our MCO clients are regulated by the Center for Medicare and Medicaid Services (CMS), as well as perhaps by state Medicaid managed care programs.  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 insurance companies, HMOs and PPOs, among others, develop and implement regulatory compliance plans. We have served as national counsel for licensing issues for our MCO clients.

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 state 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 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.  Baker Donelson lawyers have rendered cradle to grave services starting up MCOs, as well as winding them down when called for. 

Contract Development and Negotiation

Managed care contracts present complex issues of responsibility, liability and risk, with overlapping federal and state laws and regulations to consider. They demand experienced counsel.

As advisors to private payers 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 for national insurers and contracts for health plans and physician groups, alternative health care delivery organizations and newly formed MCOs.

Our objective is to help clients make sure the MCO is structured to meet their business, operational and compliance needs.

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