Managed care takes many forms — health maintenance organizations, preferred provider contracts, hospital and physician organizations, independent practitioner associations, capitated contracts, fee-for-service contracts with at-risk features, and Medicaid managed care contract payors. The Kitch firm represents all types of parties to these relationships, including HMOs, insurers, provider organizations and providers.

We appreciate the importance of maintaining positive relationships between parties despite the obstacles. In helping to develop managed care contracts, we work with our clients to avoid the situation where, even after negotiations are completed, the parties hardly speak with each other, substantially negating the objectives of the parties in having an agreement. In this respect, many years of experience on all levels of the managed care relationship permit the firm to provide balance, even where advocacy is essential for our client’s interest.

We also understand the sensitivity of positive relationships between managed care organizations and the regulators. We make it our business to understand written and unwritten regulatory requirements as well as why regulators sometimes insist upon MCOs meeting standards that seem to have no meaningful purpose. We also make it our practice to maintain cordial relations with the regulators. Through that understanding and cordiality, we are often able to do more for obtaining moderation on behalf of our clients then what pure bulldog advocacy might provide. However, we never leave the impression that our client will not fight if necessary–through the administrative process or litigation–because losing that edge could also be counterproductive to our client’s interest.

We know that even the operations of managed care can be very complex. We regularly assist MCO and provider clients in dealing with difficult issues such as incentive payment programs, messenger model negotiations, peer review confidentiality and utilization review.

Examples of the managed care work of the Kitch firm include:

Licensure of HMOs

Establishing a delegated credentialing system for HMOs and health systems

Coordinating and establishing a system for transfer of confidential peer review information between a provider institutions and HMOs for maximum confidentiality protection

Formation of physician organizations, hospital organizations and PHOs

Negotiating risk contracts, including administrative fees and various risk pools

Assisting in the development of provider credentialing programs, including individual provider contracts

Establishment of a multi-HMO management service organization

Litigation of managed care claims, including wrongful denial of benefits

Comprehensive evaluation of PHO negotiating process and payment formulas under antitrust and other laws.

Managed Care

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