Background - Practices (Details)

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 lawyers are leaders in the field of managed care law and are relied upon for their in-depth knowledge.

Our experience focuses on the litigation, transactional, and regulatory needs of health plans across the country. We have extensive experience with the California Knox-Keene Act and the insurance laws impacting plans in California and other states. We assist companies in obtaining licensure and advise them on a wide array of state and federal regulatory requirements, including change in control requirements, mandated benefits, rating requirements, marketing activities and producer arrangements, antitrust and unfair insurance trade practice laws, insurance holding company laws, financial solvency, subrogation and coordination of benefits, privacy and security breach issues, outsourcing arrangements, and relationships with providers, including prompt payment and provider risk-assumption issues.

Our lawyers also regularly advise clients on statutory and regulatory compliance issues arising under the Patient Protection and Affordable Care Act (PPACA), including issues regarding medical loss ratios (MLRs), Essential Health Benefits, internal and external claims review, premium taxes, Accountable Care Organizations (ACOs), premium rate increase reviews, provider non-discrimination, and health insurance exchanges. Our lawyers' extensive knowledge of these and many other health care reform related matters assists clients in navigating the ever-expanding and continually changing complex field of health care compliance under PPACA.

Our lawyers 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, security breach investigations, 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, in information technology and outsourcing agreements, and in provider contracts of all types, including capitation and risk arrangements.

Our lawyers are particularly recognized for the depth of their experience in federal and state health care programs. Our substantive knowledge 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 lawyers 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 the following:

  • 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 lawsuit developments affecting managed care. Please click here to access the Crowell & Moring Managed Care Lawsuit Watch.