In today’s economic environment, hospitals, physician practices, and health care entities need each other more and more in order to keep their businesses alive. Our attorneys have extensive experience in providing advice on the business and legal facets of operations, including formation and operation of independent practice associations (IPAs), physician/hospital organizations (PHOs), and management service organizations (MSOs), Provider Networks, and Accountable Care Organizations (ACOs). In addition, we provide advice on sophisticated clinical integration issues and managed care contracting and negotiating strategies with payors. We routinely draft and review provider and managed care contracts on behalf of our health provider clients.
Our attorneys have been actively involved in all aspects of alignment initiatives, including practice acquisitions, physician recruitment, employment/professional services models, and real estate ventures. We also provide strategic counseling in the areas of reimbursement, licensure, practice management, fraud and abuse (including analysis under anti-kickback, Stark law, and state laws), valuation methodologies and reports, not-for-profit tax issues, and ERISA implications. In many of the practice acquisitions we have handled, we also assisted with the real estate leases/acquisitions necessitated by such purchases.
Accountable Care Organization (ACO) formation
Our attorneys are in the forefront of the Accountable Care movement. In addition to our many years of experience with PHOs, IPAs, and managed care contacting, we are among the select few law firms in the country that have actual hands-on experience in ACO formation. For example, our attorneys represented the lead agency in a New York State Department of Health demonstration project using the ACO model, which provided first-hand experience drafting and negotiating ACO network agreements and agreements between ACOs and information technology venders.
We are continuously monitoring developments in the CMS and FTC regulatory arenas regarding the emerging guidance on payment policies, antitrust considerations, physician self-referral and anti-kickback constraints, and exceptions/safe harbors and civil monetary penalties. In particular, we are monitoring agency pronouncements regarding the circumstances in which otherwise independent providers will, under the auspices of an ACO, be permitted to collaborate and jointly negotiate payment arrangements with government payors and with insurance providers and self-insured employers without running the risk of engaging in illegal price fixing under the antitrust laws based upon their achieving the requisite degree of clinical integration.
We are also focused on CMS’s policy discussions and the requirements it will establish for ACOs to qualify to benefit from CMS’s Shared Savings Program under § 3022 of PPACA; the mechanisms that will be required for shared governance of the ACO; policies relating to an ACO’s accountability for quality, cost, and overall care of assigned Medicare fee-for-service beneficiaries; and the applicable quality of care measurements (such as clinical processes and outcomes), the expectations for the patient and caregiver experience of care, objectives for achievements related to utilization (including hospital readmission rates), ambulatory care sensitive conditions, and care transitions across health care settings. We are also familiar with the patient privacy and security issues that must be addressed by ACOs.
Our work in this area includes close coordination and partnering with the health system’s professional staff and with consulting organizations that help support the design and implementation of clinical integration initiatives.