Focusing on the unique business and legal challenges faced by the managed care community today, Nixon Peabody’s Managed Care team draws from a pool of attorneys experienced in all aspects of health law. We have more than two decades of experience representing clients in connection with risk-sharing and capitation arrangements between health plans and health care providers, including negotiation of percentage of premium and budgeted capitation arrangements subject to “withholds,” stop-loss and reinsurance arrangements, and final settlement audits and disputes. We routinely represent providers in connection with pay-for-performance programs, operational considerations, quality bonuses, gain sharing programs, fee-for-service arrangements, clinical integration initiatives, and litigation and arbitration over payor contracts
We have an exceptional understanding of the practical and operational considerations health care clients confront with managed care contracts, whether they are traditional fee-for-service or risk-based. Our team is especially conversant with the impact policies and procedures can have on the successful implementation of negotiated contract terms and have developed negotiating strategies and contract language addressing these kinds of issues.
Our attorneys represent the legal interests of a wide variety of managed care clients, including:
- HMOs, PPOs, and PHSPs (Pre-paid Health Services Plans)
- Health care provider networks
- Hospitals and health care systems
- Physicians and group practices
- Physician, dental, and laboratory practice management companies
- Mental health and developmental disabilities providers
- Ancillary service providers
- Nursing homes
- Statewide provider associations and coalitions
Our team has been involved in the establishment and representation of managed care entities and in negotiating and enforcing contracts between managed care organizations and health care providers. Our attorneys also represent physician networks in investigations by the Federal Trade Commission under antitrust laws.
In addition, we have worked on the financial (e.g., rates and capitalization payment mechanisms) and the operational (e.g., credentialing, auditing, claims processing, etc.) aspects of our clients’ agreements. We have also assisted clients in disputes with managed care organizations regarding the terms of contracts, the adequacy of adjustments, the sufficiency and accuracy of data, and settlement audits. Our litigators have handled a variety of matters involving health care issues generally and managed care in particular.