Managed Care
Crowell & Moring is nationally preeminent in providing legal services for the managed care and health insurance industry. We have worked closely with the managed care industry for many years, and bring to our services deep familiarity with the business and legal needs of our managed care clients. We represent leading managed care companies and integrated delivery systems, both for profit and not-for-profit, across the country. Our attorneys are leaders in the field of managed care law and are relied upon for their in-depth expertise.
Our extensive experience focuses on the litigation, transactional and regulatory needs of health plans across the country. We assist companies in obtaining their initial state licensure as well as advise them on the vast array of state regulatory requirements including: mandated benefits, rating requirements, marketing activities, antitrust and unfair insurance trade practice laws, insurance holding company laws, financial solvency, subrogation and coordination of benefits, privacy and security breach issues, relationships with participating and non-participating providers, and compliance with new requirements under PPACA, including issues regarding medical loss ratios ("MLRs", ACOs and health insurance exchanges. Our attorneys also assist health plans in responding to and resolving audits and other compliance investigations at the state and federal levels. We represent managed care and health insurer clients across a wide range of litigation challenges, including underpayment claims by participating and non-participating providers, antitrust disputes, RICO conspiracy claims and provider network exclusions. We also represent managed care and provider clients in the creation of business relationships, in mergers and acquisitions, in the design of marketing and network joint ventures, and in provider contracts of all types, including capitation and risk arrangements.
Our attorneys are particularly recognized for the depth of their experience in federal and state health care programs. Our substantive expertise includes a sophisticated understanding of the Medicare Advantage, Medicare Prescription Drug Plans, Federal Employees Health Benefits Program (both community-rated and experience‑rated carriers), TRICARE, and Medicaid Managed Care programs. We assist companies in preparing responses to requests for proposals, applying for government contracts and ongoing compliance activities. Our experience with these programs includes, but is not limited to, the bid or rate submission and reconciliation processes, benefit requirements, reporting obligations, marketing rules, provider contracts and subcontracts including pharmacy benefit management agreements, novation agreements and procurement disputes. We also have an in-depth understanding of the scope of federal preemption of state laws that might otherwise affect federal government programs. Our attorneys advise clients on the design and implementation of compliance programs that focus on the risk areas of their government operations, and perform compliance audits of those operations.
We also advise our managed care clients on related federal law requirements, such as:
- HIPAA privacy, security and standard transactions
- ERISA – including claims procedures, summary plan document and disclosure issues
- HIPAA portability and non-discrimination
- Medicare secondary payor
- Anti-kickback and anti-inducement
- False Claims Act
The Crowell & Moring Health Care Group also provides a summary of key lawsuits affecting managed care. Please click here to access the Crowell & Moring Managed Care Lawsuit Watch.