Contract Compliance

Managed care entities are increasingly standing in the shoes of the government in administering Medicare and Medicaid/Medi-Cal benefits. Unlike traditional fee-for-services programs that are governed largely by statutes and regulations, today’s managed care arrangements impose complex and opaque contractual requirements on healthcare providers. We support providers to ensure their practices are consistent with the obligations they have agreed to. 

Medicare Advantage and Medicaid/Medi-Cal managed care plans carry additional risks because of federal and/or state funding. For example, improper billing can give rise to allegations under the False Claims Act. However, identifying the rules governing each plan is not always straightforward—fee-for-service requirements and governmental guidance is often fragmented or evolving. Athene Law is uniquely positioned to advise clients on governmental contract compliance matters.

In other circumstances, violations of managed care contracts may have other significant impacts on a provider, including the reduction or denial of payment for medically necessary services, or in extreme circumstances, termination from plan networks.

Capabilities

Clients across the healthcare industry, including physicians and group practices, healthcare facilities, hospitals, health systems, and both for-profit and non-profit organizations, turn to Athene Law for strategic guidance and effective representation in navigating managed care contract compliance.

Athene Law’s diverse experience within the healthcare industry has prepared the team to represent practices and professionals in a highly-regulated environment.

We have advised clients on payor contract compliance issues, including:

• Billing practices and documentation requirements
• Compliance with the No Surprises Act, including balance billing restrictions, the “gag clause” prohibition, provider directory requirements, and notice/disclosure obligations
• Changes of ownership, change of information, and change of control processes
• Delegated functions and oversight responsibilities
• Submission of encounter data and quality reporting
• Credentialing and re-credentialing requirements
• Timely and accurate completion of attestation forms and certifications
• Coordination of benefits and third-party liability compliance
• Regulatory audits and health plan monitoring reviews
• Reporting of fraud, waste, abuse, or identified overpayments