Contract Negotiation

Athene Law supports its clients in negotiating managed care contracts that are both financially sound and legally protective. We combine our deep regulatory expertise in governmental reimbursement, the Knox Keene Act, and ERISA, with our experience litigating managed care contract disputes. In doing so, we provide clients with strong language to ensure they are paid for services rendered to patients.

We advise clients to ensure that they align business objectives with legal and regulatory requirements in negotiations with health plans. This includes the creation of new models of collaboration, including subdelegation agreements, case management/community support agreements, value-based purchasing, or shared savings models.

We ensure contracts include our vetted language around contentious issues, such as improper denials, unnecessary data requests or audits, regulatory amendments, and more. We collaborate on financial analyses to support strategic business decisions.

We also keep an eye out for specific regulatory requirements that plans insert into contracts asserting that they are required by government programs. We push back on overreach, ensuring provisions are limited to what is mandated by law or what may be needed to access Medicaid supplemental payments.

Capabilities

Clients in the healthcare industry, including physicians and group practices, healthcare facilities, hospitals, health systems, and both for-profit and nonprofit organizations, rely on our guidance to navigate the complexities of payer contracting. Whether entering a new agreement or negotiating an existing one, we help clients identify, address, and resolve the terms that carry the most operational and financial risk.

Some issues we have addressed in payer contract negotiations include:

• Protection against improper claim denials and excessive documentation requests
• Audit provisions and documentation requirements
• Reconciliation and dispute resolution for underpayments and recoupments
• Limitations on payer authority to unilaterally amend key contract terms
• Termination clauses and notice periods
• Contract renewal terms, auto-renewal language, and exit strategies
• Credentialing and network participation requirements
• Coordination of benefits and secondary payer obligations
• Dispute resolution procedures, including venue and governing law

• Provisions related to regulatory changes and downstream obligations under governmental programs
• Clear and enforceable rate descriptions to avoid ambiguity, including alternative payment models