Understanding the intricacies of health care regulations, insurance law, reimbursement, corporate structuring and antitrust, we help clients improve their market position through innovative alliances among health care providers, commercial payers and self-insured employers. We advise on clinical integration, population health management and care coordination strategies and the development, operation and restructuring of virtually every type of provider network, including ACOs, PHOs, IPAs, "super CINs" and specialty specific coalitions.

Broad legal support for health care network structuring and formation

Our health care team offers a full array of services our clients need to successfully structure and operationalize provider networks and innovative managed care alliances. We prepare governance documents, committee charters, compliance programs, antitrust protocols, participating provider agreements and unique payer-provider arrangements. We help draft ACO, Bundled Payment for Care Initiative and other program participation applications, advise on participation requirements and facilitate regulatory filings. And we counsel on incentive distribution methodologies, the scope and application of regulatory waivers, medical management programs, marketing materials, provider outreach, contracting strategies, credentialing plans and delegated credentialing arrangements. Our attorneys work with a variety of reimbursement methodologies, including shared savings, bundled payment, pay-for-performance, HQEP, capitation, subcapitation, multiple risk pools and withhold incentives.

Drawing on considerable antitrust strength, we structure provider networks to ensure that they are sufficiently integrated to pass muster under antitrust laws, and we perform clinical integration reviews to identify steps that networks can take to bolster their antitrust positions. Our attorneys structure each arrangement based on careful analysis of the regulatory framework, as well as current market dynamics and client objectives. Clients also rely on us for guidance on issues related to:

  • antitrust
  • fraud and abuse (including Stark Law and Anti-Kickback Statute)
  • physician self-referral
  • fee splitting
  • corporate practice of medicine
  • insurance laws
  • licensure
  • consumer protection
  • mandated benefits
  • confidentiality of information

Our clients include health systems, physicians, multiprovider networks, disease state management companies, trade associations, insurance companies and other managed care organizations. We represent nearly every type of provider and managed care network, ranging from provider-sponsored ACOs to unique affiliations among insurance companies and health systems. Dental and vision programs, third-party administrators and internet-based service providers also seek our counsel regarding the development and operation of, and participation in, Medicare, Medicaid and commercial managed care programs.