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In Brief: A Digest of Payor and Managed Care Projects

Client Success

Payment Disputes

  • Successfully represented one of the nation’s largest medical institutions in arbitration against a national insurer to recover on multiple years of underpayments pursuant to a managed care contract. We secured a favorable multimillion-dollar award for our client (including attorneys’ fees and interest).
  • Represented a large physicians group and secured a $4+ million payment under a risk-sharing agreement.
  • Represented a children’s hospital in recovering $5 million in a payment dispute.
  • Represented a large medical center in successful litigation against an insurer to recover underpayments under a state Medicaid program.
  • Handled matters against private managed care companies under contract with the states (Medicaid managed care), involving a combination of arbitration, mediation and state administrative appeal.

Contracting and Compliance

  • Represented a large managed care business operating in five states in creating a network IPA; creating and negotiating participating provider agreements with physicians that include fee-for-service and risk-sharing arrangements; acquiring physician practices and medical groups, including the acquisition of hospitalist practices that support in-patient services for which the client is at risk; and assisting with joint ventures with larger medical groups.
  • Represented one of just five hospitals nationwide selected by CMS to be an Acute Care Episode (ACE) Demonstration Project for a bundled payment approach to selected cardiology and cardiovascular surgery procedures. CMS gave the hospital wide latitude to design its own approach to combine all of the professional services providers for these procedures into one bundled payment from Medicare to the hospital, with the Hospital then paying each provider in accordance with pre-set negotiated amounts. Our firm was substantially involved in the ACE program design, including the risk-sharing structure that was used to split the bundled payment from Medicare among all providers involved in a patient’s care. We drafted and negotiated all provider and provider group agreements and were heavily involved in structuring and drafting the agreements that comprised the gainsharing program component of the project.

Revenue Cycle Audits

  • Routinely counseled a healthcare system with respect to potential compliance issues associated with its revenue cycle process and procedures. Assisted in the evaluation and resolution of such matters.
  • Engaged outside revenue cycle consultants through attorney-client privilege for a children’s hospital as part of its audit work plan. We managed the audit and provided compliance guidance as well as evaluated proposed revenue cycle opportunities to improve reimbursement.
  • Prepared and negotiated contracts with revenue cycle, supply chain and software vendors for a large hospital system, and advised in-house personnel regarding best contracting practices.