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:
- Contracted reimbursement amounts
- Contract length and contract provisions that can change during the term of an arrangement
- Contract termination, including notice obligations and hearing rights
- Per diems and identification of services that are included or excluded
- How DRGs are defined and how outliers are treated
- When reimbursement is defined by reference to Medicare reimbursement and how rates are measured with reference to updates by Medicare or set by fixed rates
- How “down coding” is defined and what gets paid for
- Admission versus observation
- Simple errors in billing versus allegations of fraud
- Leased and “rental” networks
- Silent PPOs
- Placement in tiered networks
We provide representation in all of the forums available to resolve disputes, including some not often thought of, including:
- First level internal appeals
- Mediation and arbitration
- Litigation in the New Jersey Office of Administrative Law, the New Jersey Superior Court, Law, Chancery and Appellate Divisions, and the New Jersey Supreme Court
- Office of the Insurance Fraud Prosecutor
- New Jersey Medicaid Fraud Division
- Provider Reimbursement Review Board
- Complaints to regulators at the Department of Banking and Insurance and the Department of Labor
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.