What We Do
Managed care is where the business of healthcare intersects with healthcare law, and our clients turn to us to navigate through both of these unique and ever-changing landscapes.
This includes assistance with a wide range of managed care matters, including commercial and governmental payor managed care contracting and strategy, payor protocols and policy disputes, defense of payor audits, analysis of regulatory changes, and optimization of operational efficiencies.
Capabilities
Contracts
Wolfe Pincavage’s Managed Care team assists in the drafting, negotiation, and implementation of managed care contracts. With years of experience resolving healthcare payment disputes, we understand the importance of language in managed care contracts to limit exposure to risk, maximize provider’s bottom line, and decrease administrative burden.
We regularly negotiate and draft new contracts, amendments, and regulatory addenda for our clients’ arrangements with:
- Commercial Health Plans
- Behavioral Health Plans and Carve Out Vendors
- Transplant Plans and Carve Out Vendors
- Governmental Health Plans Such As Medicaid, Tri-Care, & Medicare Advantage
- International Health Plans
- Third-Party and Other Rental Networks
Strategy & Structure For All Types of Managed Care Relationships
Our in-depth knowledge and experience with managed care contracting and disputes allows us to understand complex relationships between providers and payors. We leverage our in-proficiency to devise system-wide managed care strategies that maximize provider revenue.
Contract Termination Counseling
Wolfe Pincavage understands the impact a payor contract termination has on the provider’s organization and its patients. When termination is imminent, our firm’s Managed Care team supports the client throughout the entire process, including termination strategy and consultation regarding notice requirements, continuity of care, patient and other stakeholder communications, and, if applicable, implementation of state and federal out-of-network arbitration processes.
Operations
We proactively counsel our clients on how to remain in compliance with various new and existing laws and regulations that impact managed care, as well as provide guidance on how to achieve operational efficiencies in the client’s revenue cycle. Our operational guidance touches upon various aspects of our client business including:
- Operational forms, including good faith estimates, advance beneficiary notices, insurance opt-out forms, self-pay agreements, etc.
- Assignment of benefits and financial responsibility agreements
- Billing and collections practices
- Delegated functions, including delegated credentialing
- Payor audits
Regulatory
The unique regulatory and business concerns in healthcare necessitate attorneys who are well versed and connected, not only in the legal profession, but with hospital administration and industry leaders. We provide practical compliance advice that clients can implement in daily operations, covering areas such as:
- Billing & Collections Compliance
- Licensing
- Medicare & Medicaid
- Affordable Care Act
- No Surprises Act
- Price transparency
- Fraud and abuse
- Corporate Practice of Medicine/Health Care Clinic Act
- State and federal privacy laws
Policy & Procedure Creation
Policies and procedures should be customized and adaptable to better meet the needs of your organization. We craft attainable policies and procedures to ensure compliance with laws and regulations, including:
- Billing and collections policies and procedures
- Health plan policy issues
- Audit and medical record access policies
