Leading edge mastery of health reform under and beyond the Affordable Care Act.
■Educate state executive, legislative and agency leaders on options and opportunities for establishing and operating state-based health insurance exchanges, including organizing academic symposium to examine performance of state-based exchanges
■Support health industry trade association and member organizations with development and analysis of private coverage options for state Medicaid expansion under the Affordable Care Act
■Furnish strategic counsel, advice and interpretation for myriad issues under the Affordable Care Act and its implementing regulations affecting health insurance markets and products and Medicare and Medicaid programs
■Conduct Affordable Care Act and state insurance law compliance reviews and assessments of health insurer policy forms for individual, small group and large group markets on and off exchange
Strategic and Operational Transactions and Contracting:
Skilled in structuring, negotiating and documenting health industry joint ventures, affiliations, alliances and other strategic transactions, company-critical business process and administrative outsourcing arrangements, and health IT licensing and services deals.
■Structure and document physician-hospital organization for hospital system and affiliated physicians for payer contracting
■Structure, negotiate and document care coordination and value-based payment arrangements between health plans and provider organizations and their participating providers
■Structure, negotiate and document commercial and government health program pharmacy benefits management agreements
■Negotiate and document vendor arrangements for performance measurement and improvement, quality reporting and population health services
Antitrust & Fraud & Abuse Compliance:
Long experience with and keen knowledge of antitrust and fraud and abuse issues affecting business operations, arrangements and relationships.
■Counsel, provide litigation support and interact with federal and state antitrust agencies investigating and challenging health industry mergers and acquisitions, including health plan mergers and hospital acquisitions of competing facilities and physician practices
■Counsel and advise on antitrust and fraud and abuse implications of health care arrangements and activities, including mergers, acquisitions and joint ventures, payer-provider most-favoured nation clauses, collaborations and joint negotiations, and accountable care organizations
Health Data Privacy & Security:
Unmatched knowledge and comprehension of HIPAA and other health data privacy and security statutes and regulations.
■Counsel and support early stage and emerging technology companies on managing collection, use and disclosure of health data, business associate arrangements and contracting, and data protection compliance in the health sector
■Advise health industry trade association on privacy management for electronic health information exchange to support member organizations’ accountable care and medical home initiatives
■Guide state university in determining HIPAA and FERPA implications of its student health insurance and health care services arrangements and assessing compliance options
■Structure, negotiate and document payer, provider and vendor arrangements for electronic health information exchange for Medicaid medical home pilot
Government Health Programs:
Fully conversant with the requirements and obligations for Medicare, Medicaid and other government health program participation.
■Transfer and novate health insurer’s Medicare Advantage, Medicare Part D and Medicare-Medicaid dual eligible contracts to subsidiary formed to focus on government business
■Advise and assist with structuring, documenting and implementing government-mandated programs for Medicare and Medicaid compliance, fraud, waste and abuse control, and vendor oversight
■Counsel on effective self-disclosure of government health program non-compliance to federal and state regulators