Managed Care

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. 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.