Practice

Regulation of Healthcare Payers

Practice solutions to complex problems

We assist healthcare payers, including Medicare Advantage and Part D plans, Medicaid managed care plans, pharmacy benefit managers and commercial insurers in navigating their role within one of the most complex, intricate, and constantly changing areas of the law.

Our healthcare lawyers and policy specialists have had a direct hand in shaping virtually every healthcare law and regulation enacted over the past four decades. With a comprehensive knowledge in statutory and regulatory analysis, healthcare compliance, government investigations, litigation and corporate transactions, we know how to prepare payers to successfully operate in a heavily regulated environment. 

Areas of Focus

Our team helps payers reduce costs, improve quality of care and align with value-based care reimbursement by:
  • Monitoring statutory changes affecting the Medicare and Medicaid programs
  • Tracking program regulatory and subregulatory developments on a daily basis
  • Drafting comments on proposed rules
  • Understanding and updating on the intricacies of access and payment policies
  • Maintaining relationships with key legislators and government regulators

Experience

LITIGATION
  • We successfully challenged the application of state anti-competitive and anti-PBM laws on the Employee Retirement Income Security Act (ERISA) and Part D preemption grounds.

HEALTHCARE COMPLIANCE
  • Our firm represented large insurers on compliance with the risk adjustment standards in the Medicare Advantage program.
  • In a Centers for Medicare & Medicaid Services (CMS) audit, our lawyers represented a Medicare Part D plan regarding compliance with program formulary requirements.
  • We have advised hospitals and Medicaid managed care plans regarding compliance with Medicaid’s institution for mental disease (IMD) exclusion policy and changes to the policy in the 2016 Medicaid managed care regulation.

Statutory and regulatory analysis
  • Our attorneys counseled a trade association representing Medicaid managed care plans on the application of the Affordable Care Act’s health insurance tax to those plans.
  • Our firm helped a Medicare Advantage plan assess the Health Insurance Portability and Accountability Act (HIPAA) consequences of a data breach and developed a process for weighing the merits of disclosure.
  • We assisted a Medicare Advantage plan secure designation by a state Medicaid agency and CMS as a dual-eligible special needs plan (Dual SNP).

News & Insights

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Our attorneys share their points of view on regulation of healthcare payers matters.