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From inception to dispute resolution, members of our Healthcare Department have in-depth knowledge of managed care contracting and integrated delivery systems as healthcare delivery and reimbursement shifts from fee-for-service to value-based care. Our experience in working with providers, payers, and state and federal regulators provides the context for our ability to adeptly recognize pitfalls in the initial managed care contracting process and to represent provider entities in disputes with commercial payers, traditional Medicare, Medicare Advantage and Medicaid.

The firm’s expertise in managed care contracting covers the gamut of ultimate payers, including Medicare Advantage (CMS), Medicaid MCOs (CMS and New Jersey DMAHS), and commercial health plans including insured (carriers) and self–insured (employers). Regardless of the ultimate payer, carriers paid on a capitated basis are incentivized to depress reimbursement, and to apply restrictive medical policies.

With experience representing both providers and payers in managed care contracting negotiations – and as former regulators who drafted many of the rules which govern managed care contracting and organized delivery systems in New Jersey – members of our team provide invaluable assistance to clients who are navigating complex regulatory schemes and complicated contractual disputes. Our work encompasses issues related to:

We provide representation in all of the forums available to resolve disputes, including some not often thought of, including:

In an age when agreements with payers move further into the arena of risk-sharing (including arrangements emanating from the CMS Center for Innovation such as episode-based care initiatives and ACOs) healthcare facilities and industry groups have either plunged in with our guidance and support or watched from the sidelines. Providers in both camps are looking to leverage these approaches and share in the gains their efficiencies and effectiveness have created. We assist our clients in examining and navigating their arrangements with commercial payers and the inevitable introduction of state oversight, as well as certification or licensure requirements as the reach extends beyond traditional Medicare.