Health care reform has accelerated the growth of managed care organizations and delivery models. Managed care organizations and delivery models are positioned for continued growth in an era of cost reduction initiatives and tighter review of utilization and medical necessity. Many healthcare providers have grown or seek to grow into risk-bearing organizations, while many health plans seek to develop their own provider functions.

From selective contracting to pay-for-performance and cost-sharing models, from accountable care organizations to patient-centered medical homes, managed care entities and models raise a host of business and regulatory concerns.  Nelson Hardiman works with a wide range of managed care entities to navigate regulatory challenges. Nelson Hardiman’s team of experienced attorneys has advised many managed care organizations, both on strategic issues and tactical, problem-focused engagements. Clients depend on our depth of experience in healthcare licensing, operations, and reimbursement, coupled with our expertise in the compliance requirements for managed care entities under the Knox-Keene Act and the Employee Retirement Income Security Act (ERISA).

Our managed care clients include physician networks, independent physician associations (IPAs) subject to the solvency requirements for risk-bearing organizations (RBOs) of the California Department of Managed Health Care (DMHC), and limited Knox-Keene licensees that contract to accept delegations of hospital risk. We provide compliance advice to Medicare Part C and Part D health plans, as well as their first-tier, downstream, and related entities. Nelson Hardiman also represents many management services organization (MSOs) and physician-hospital ventures. From addressing Medicare and HIPAA compliance issues and investigations to creating integrated delivery systems, from negotiating contracts to developing payment structures, Nelson Hardiman works with large and small managed care providers in all aspects of their businesses. Our experienced team of attorneys understands the nuances of the managed care delivery models and has a long history of success advising its managed care clients.