Managed care is one of the most heavily regulated sectors of the health care industry, and every state has its own rules. Providers need sophisticated advisors who can respond quickly and adeptly to the complex and evolving legal, regulatory, and business issues inherent in working with managed care organizations (MCOs). Baker Donelson's attorneys have years of hands-on experience – both as in-house and outside counsel – serving as trusted advisors to for-profit and not-for-profit providers across the full spectrum of health care services.
With mounting pressure to slash costs, the aggressive techniques and strategies of the managed care sector – once confined to health maintenance organizations – have become ubiquitous. Baker Donelson provides strategic counsel to leaders in the health care industry as they navigate private and public payors' persistent efforts to reduce payment to providers. We regularly represent clients in regulatory, compliance, and operational issues related to managed care.
We know the law. And we know the business of health care.
Contract Development and Negotiation
Negotiating contracts with MCOs presents complex issues of responsibility, liability, and risk, with overlapping federal and state laws and regulations to consider. Baker Donelson's attorneys have deep experience negotiating a wide range of agreements, from hospital system contracts to contracts involving health plans and physician groups and alternative health care delivery organizations. As advisors to numerous regional and national health care providers, our objective is to help clients structure their agreements to effectively meet their business, operational, and compliance needs.
Litigation
Litigation against MCOs is on the rise nationwide, with payors using their market leverage to force providers into accepting pennies on the dollar for medically necessary, life-saving care. Baker Donelson's managed care litigation attorneys are at the forefront of the fight for providers against the nation's largest payors. Our in-depth knowledge of reimbursement practices, Medicare and Medicaid rules and regulations, health care operations, contract negotiations, and the rigid billing practices of MCOs position our litigators to aggressively protect clients' interests in all manner of litigation involving managed care, from payor-provider disputes (both in- and out-of-network), to False Claims Act litigation, to class actions and Employee Retirement Income Security Act (ERISA) litigation.
Our attorneys are particularly experienced in handling reimbursement-related disputes on behalf of health care providers against payors, including Medicare Advantage Organizations, Medicaid MCOs, and government payors. The team has represented health care providers bringing payment disputes in federal and state courts, the Medicare Provider Reimbursement Board, state Medicaid appeals agencies, and national arbitration associations. Our team understands and has demonstrated – through measurable results – that there is a path forward for providers who render medically-necessary care to patients yet have been subject to the questionable tactics and strategies of MCOs involving the improper denial, underpayment, and nonpayment of claims for medically-necessary items and services.
Our extensive experience includes representation of:
- Academic medical centers
- Anesthesia providers
- Behavioral health providers
- Children's hospitals
- Dialysis providers
- Emergency service providers
- Home health providers
- Hospice providers
- Hospitals and health systems
- Long term care providers
- Provider networks
- Telehealth providers