We are tactical problem-solvers in an era of healthcare reform driven by cost reduction initiatives and heightened review of utilization and medical necessity. Nelson Hardiman lawyers help managed care providers navigate the industry’s most complex business and regulatory concerns. Our experienced team understands the nuances of managed care delivery models and has a successful history advising managed care businesses.

Our clients depend on Nelson Hardiman’s deep experience in healthcare licensing, operations, and reimbursement, combined with our expertise in the compliance requirements for managed care entities under the Knox-Keene Act and the Employee Retirement Income Security Act (ERISA). We address Medicare and HIPAA compliance issues and investigations, help create integrated delivery systems, negotiate contracts and develop payment structures. From strategic issues to solution-focused engagements, Nelson Hardiman resolves the legal challenges of managed care entities.

Physicians challenged by the changing reimbursement and regulatory landscape rely on Nelson Hardiman to navigate complex health care plan options that form the basis of Independent Physician Associations (IPAs). We negotiate health care plan agreements that deliver seamless solutions for IPA members beset by administrative burdens.

Our healthcare attorneys blend their next-level healthcare management skillset with expertise on payor compliance issues to advise IPA physicians on effective health care plan options. We work with you to identify plans and processes that work with your business structure – be it a nonprofit entity, a limited liability company, a corporation or other type of shareholder-owned entity. Our experience includes structures that allow members to care for patients outside of contracted health care plans. Bottom line, Nelson Hardiman delivers the power of strength in numbers to our IPA clients, ultimately providing a platform for IPA physician members to preserve capital and share risk, maintain independent practices, and participate in coordinated care to improve patient outcomes.

Our Work Includes:

  • Acquisition Negotiated the purchase and sale of an IPA offering forward-thinking care delivery and payment models to an equity investor based on the market potential for value-based care.
  • Business Litigation Represented an IPA in complex disputes regarding exclusive provider contracts, transactional misrepresentations, and shareholder disputes.
  • Compliance Advised an IPA in Palm Springs, California on Knox-Keene Act and Department of Managed Health Care (DMHC) solvency requirements for risk-bearing organizations.
  • False Claims Act Defended an IPA in False Claim Act/qui tam whistle-blower litigation about alleged claims violations involving the IPA’s healthcare plans.
  • Formation, Contracts and Operations Formed several new IPAs, merged physician practices, negotiated new contracts with Medicare Advantage plans, and counseled on business and regulatory aspects of IPA operations.
  • Reimbursement Audits and Investigations Represented numerous IPAs in reimbursement audit and investigations by governmental payors, including Medicare and Medi-Cal.
  • Stark and Anti-Kickback Compliance Counseled a primary care IPA on Stark and Anti-Kickback compliance and utilization review requirements in connection with a proposed new healthcare plan structure.

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.

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.

Our leadership position in the healthcare industry makes us adept at understanding the unique business needs of Management Services Organizations (MSOs). Because we know every aspect of healthcare law, we frequently sit at the same table with MSOs and providers. We are masters at the complex issues that arise around practice management related non-medical business functions. We hammer out MSO legal agreements around the corporate practice of medicine doctrine and help MSOs navigate the fraud and abuse arena, including anti-kickback, self-referral and fee-splitting regulations. MSOs rely on us for our highly-attuned sensitivity to the complex interplay between developing integrated practice care standards and realizing savings with third party payors, based on our shared vision of transforming the delivery of healthcare services.

Our Work Includes:

  • Acute Care Hospital Acquisition Counseled and documented management company in acquisition of acute care hospitals both in and out of bankruptcy court, involving workouts and operational turnarounds.
  • Billing Dispute Prevented litigation between physicians and billing company over the denial of claims by the Centers for Medicare and Medicaid (CMS).
  • Digital Healthcare Referral Services Advised a chiropractic entity on the engagement of a website referral service, analyzing business models and counseling on potential fee-splitting, Stark, Anti-Kickback, and other regulatory compliance issues.
  • Healthcare Factoring Worked with MSOs to structure a factoring transaction for six healthcare providers and three investment firms involving $20 million in workers’ compensation accounts receivable in response to changes brought forth by California Senate Bill 1160.
  • Knox-Keene Act Advised MSO on relationships with Knox-Keene entities.
  • Healthcare Management Companies Set-up over fifty management companies to assist with management and financing for health care facilities including hospitals, medical practices, MediSpas, 1206 Foundations, and related entities.
  • Medical Billing Defense Obtained a favorable settlement for a medical billing provider in a billing dispute involving a million dollars in Medicare and private insurance claims.

Nelson Hardiman’s undisputed knowledge of the healthcare sector and keen insights into industry trends inspires our counsel on physician-hospital ventures. Providing support for the realignment of the healthcare industry, we structure entities that benefit patients, physicians, and hospitals. We negotiate complex financial vehicles and address the full spectrum of business, regulatory and strategy concerns to build and sustain physician-hospital ventures.

Our leadership at the intersection of healthcare law and innovation drives our experience with physician-hospital joint ventures. We represent multispecialty and orthopedic ambulatory surgery centers, cardiac catheterization, cardiovascular CT imaging, vascular services, orthopedic, heart, spine, neuro-spine, and surgical specialty hospitals and many other ventures. We combine regulatory counsel on Stark and anti-kickback laws with financial acumen encompassing joint equity ventures, participating bond transactions (PBTs), and contractual integration. Nelson Hardiman aligns the goals of physicians and hospital management to create strategic growth models united by a shared vision for physician-hospital ventures.

Our Work Includes:

  • Ambulatory Surgery Centers Documented the financing and/or sale of over 25 ambulatory surgery centers.
  • Business Advised on entity formation and business structure for various hospital-physician ventures.
  • Class Action. Represented out-of-network outpatient surgery centers (ASCs) in federal putative class action against healthcare insurers, and numerous ERISA plans for alleged failure to reimburse the ASCs according to a proper methodology for calculating the usual, customary and reasonable (UCR) reimbursement as set forth in the plans.
  • Clinics Negotiated clinical ventures between hospitals and affiliated physicians.
  • Licensing Advised on Knox-Keene and Department of Managed Health Care (DMHC) license application requirements for physician-hospital ventures throughout California.
  • Mergers and Acquisitions Handled complex transactional matters, including mergers and acquisition and joint ventures, for physician-hospital ventures.
  • Restructuring Represented the borrower in obtaining a $15.8 million syndicated loan facility to restructure 12 physician clinic practices and ambulatory surgery centers located in California.
  • Securities Finance For a physician-hospital joint venture, created a new security worth $100 million as a bond-equivalent for hedge fund seeking stable but higher returns, based on cash flows captured from healthcare organizations.