Nelson Hardiman has decades of on-point experience with managed care entities. Envisioned as a transformative for-profit model driven by the insurance industry, we cut our teeth on Health Care Maintenance Organizations (HMOs), the first form of managed care. Today we use our business acumen and first-hand knowledge of healthcare systems to provide strategic and practical guidance on operational, regulatory, transactional, and litigation matters for limited Knox-Keene and HMO entities.
Nelson Hardiman’s healthcare attorneys have navigated every conceivable legal issue for the managed care entities that provide healthcare to 90 percent of insured Americans. We address the key managed care issues impacting providers throughout the U.S., representing limited Knox-Keene licensees and health maintenance organizations (HMO’s), including Medicare Part C plans. What sets us apart is our focus on healthcare innovation and next generation healthcare and our track record of leadership in the healthcare industry.
Related PracticesGovernment InvestigationsLitigationRegulatory ComplianceTransactions
Our Work Includes:
- Business Facilitated the conversion of a nonprofit HMO to for-profit status, and negotiated subsequent chain affiliation.
- Business Formation and Structure Advised on entity formation and business structure for several new HMOs entering the market as for-profit plans.
- HIPAA and Privacy Counseled HMOs on HIPAA and state health information privacy laws and development of privacy compliance programs.
- IPA Defense Represented an IPA in a five-year action against a laboratory, defending against numerous claims and legal theories seeking more than $1.5 million for lab testing performed after termination of the parties’ agreement.
- Knox Keene Act. Obtained dismissal of a California Knox-Keene Act complaint that targeted a patient admitted through the emergency room and then sued our Medicare-HMO client for a large out-of-network bill.
- Medicare Part C Provided Medicare Part C compliance counseling to a managed care plan provider.
- Provider Reimbursement Achieved a favorable settlement recovering hundreds of thousands of dollars in a “reasonable and customary” dispute involving an out-of-network capitated medical group payor.
- Regulatory Provided regulatory defense and representation at Department of Managed Health Care (DMHC) investigations and hearings for numerous managed care providers doing business in California.
- Reimbursement Disputes Litigated out-of-network and in-network reimbursement cases and responded to special investigation audits for several local HMOs and IPAs.