Formed and handled all regulatory, operational and contracting work for one of the first and largest Accountable Care Organizations formed under provisions of the Affordable Care Act.
Advised clients on the negotiation of managed care contracts and provider network formation.
Created regional commercial Accountable Care Organization designed to improve quality and reduce costs through IPA relationships with more than 500 physicians.
Formed an IPA affiliated with a multi-hospital joint venture in Alabama involving both for-profit and not-for-profit hospital systems and provided ongoing representation.
Regularly represented PHO on regulatory and antitrust issues for Georgia non-profit hospital system.
Provided advice to Mississippi IPA on antitrust issues, payor issues, contract interpretation, vendor agreement interpretation and negotiation, general business law issues and litigation matters.
Ongoing representation of miscellaneous hospitals in connection with multiple PHO and IPO matters, including restructuring designed to reduce operating risk.
Represented hospital in forming a physician-hospital organization.
Provided antitrust advice, including implementation of “modified messenger model”, for multi-hospital PHO.
Represented multi-specialty physician IPA on organizational matters and issues involved in payor contracting, including use of the messenger model.
Represented physician practice affiliated with non-profit hospital system in formation of IPA to take capitated contracts.
Drafted and implemented compliance plan for PHO affiliated with multi-hospital joint venture.
Managed Care Disputes
Counseled gamma knife center in connection with claim to collect amounts owed for underpaid/unpaid claims for reimbursement for treatment provided to health insurer's members. Case resolved with payment of approximately 80% of all claims.
Counseled national cancer care provider in connection with reimbursement and recoupment dispute with Medicare Advantage health plan. Case resolved without repayment of any funds to plan.
Successfully defended regional managed care organization in connection with wrongful death, negligence and breach of contract claims arising from utilization review determinations.
Counseled regional not-for-profit healthcare system in connection with claim to collect approximately $7,000,000 in underpaid/unpaid claims for reimbursement for hospitalization and medical treatment provided to health insurer's members. Case resolved in favor of healthcare system with payment in excess of $6,000,000.
Represented individual healthcare provider in connection with appeal of decision to terminate provider agreement due to alleged billing irregularities resulting in the reversal of the termination and avoiding report to National Practitioner Data Bank and state licensing board.
Counseled regional non-profit healthcare system in connection with multi-million dollar recoupment dispute with national health insurer. Matter resolved without repayment of any funds.
Successful defended and settled more than $1 million in claims. Prosecution of claims against defunct managed care organization in TennCare system.
Counseled regional non-profit healthcare system in arbitrations involving reimbursement disputes with health insurers. Recovered over $6.2 million in additional reimbursements (original claim $7.2 million) in connection with dispute with national managed care organization. Recovered $1.3 million in additional reimbursements (original claim $1.3 million) in connection with dispute with national insurer.