Copyright 2019 by Susan M. Erickson, Esq.

 AREAS OF EXPERTISE

 

 Ms. Erickson has developed expertise in a wide array of legal issues and challenges facing health care payors, providers and health care services companies during her 25 years in practice.

Medicaid Health Plan In-House General Counsel Experience

 

Represented Medicaid managed care organization (MCO) at executive level meetings held by Medicaid Health Plan Operations staff at the Texas Health and Human Services Commission (HHSC)

• Negotiated initial Medicaid/CHIP managed care services contracts, and amendments to same, with the HHSC  

• Reviewed draft amendments to state Medicaid/CHIP contracts and submitted written comments and suggested revised language to HHSC

• Reviewed and submitted written comments to HHSC regarding proposed changes to the Uniform Managed Care Manual 

• Worked on the company’s initial (2013) and renewal (2014) Health Insurance Marketplace product, service area, and network filings with TDI and CMS.

• Responded to discovery requests issued by HHSC’s Legal Department relating to the Frew corrective action plans and the Alberto N. settlement agreements.

• Collaborated extensively with outside counsel that was hired to handle litigation matters, including by serving as a subject matter expert on Medicaid and on MCO business practices; drafted responses to written interrogatories, requests for admission, and requests for production.

• Analyzed legislative bills prior to and after their passage and prepared memoranda for company senior executives that described the bills’ anticipated impact on the company’s lines of business

• Prepared the company’s medical directors for participation in Medicaid Fair Hearings, including by researching the applicable sections of the Medicaid Manual, in particular the Children’s Services Handbook

• Managed the proceedings of pre-termination provider appeal panel hearings held in compliance with the Texas HMO Act.  

• Drafted Stark Law-related and other conflict of interest checklists included in company’s credentialing packets for new entrants into the provider network.

• Reviewed physician responses regarding ownership of businesses providing “designated health services” to determine the potential for a Stark Law violation

• Drafted and edited portions of every RFP response submitted by the company to HHSC over an 8-year period; the company had a highly successful rate of being awarded new contracts and new service areas pursuant to these RFP submissions

• Launched the compliance program for the company’s STAR Health (Foster Care) Medicaid managed care program beginning in 2007, including drafting all compliance. Health Passport, and privacy-related policies and procedures; drafting Foster Care amendments to all provider contracts; drafting and negotiating Foster Care agreements with all subcontractors; and, intensive work with subcontractors to develop and draft their respective P&P for the Foster Care program, culminating in a successful and on-time readiness review approval by HHSC

• Worked with HHSC to prepare informal and formal responses to member, provider, and legislative complaints

• Produced documentation in response to an Office of the Attorney General Civil Investigative Demand, which was subsequently closed with no findings.

 

Contract Drafting and Negotiation Experience

 

• Drafted initial subcontracts, and amendments to same, with Medicaid MCOs’ dental, behavioral health, vision, disease management, pharmacy benefit management (PBM), and nurse hotline subcontractors

• Drafted and negotiated tremendous variety of provider services agreements between MCOs and health care providers, including hospitals, physician-hospital organizations (PHOs), 5.01(a) non-profit health corporations, independent practice associations (IPAs), physicians, nursing facilities, and ancillary service providers

• Designed and prepared documentation for physician incentive plan addenda to standard physician services and PHO services agreements

• Drafted myriad of contracts between MCOs and third party vendors, including EVV (electronic visit verification) providers, health and wellness coaching providers, HEDIS data collectors, credentialing verification organizations, data mining companies, and claims review companies

• Drafted and negotiated confidentially and non-disclosure agreements and HIPAA business associate agreements

• Drafted and negotiated settlement and release of liability agreements with providers and third party vendors

 

 

General Health Insurance and Managed Care Legal Experience

 

• Served as retained outside counsel for provider-sponsored health plan and health insurance company on variety of state and federal regulatory and contractual matters

• Steered a variety of filings through the regulatory approval process at the Texas Department of Insurance, to include:  Form D Affiliate Transaction Statements; Applications for Certificate of Authority as a Health Maintenance Organization; HMO Service Area Expansion Applications; Health Insurance and HMO Policy and Benefit Plan filings; Network Access Plan filings; and, Utilization Review Agent Renewal Applications and Update filings.

• Submitted and received approval of a variety of filings made with HHSC, to include:  Medicaid MCO provider contract templates; significant traditional provider termination requests; delegated service agreements; and, provider and member materials relating to changes in utilization management policies

• Submitted letter briefs on rule-making initiatives to CMS (on the Medicaid-Medicare Plan (“MMP) products, for example; to HHSC; and to TDI.

• Successfully defeated numerous open records requests for clients’ confidential information sought via requests submitted to state agencies pursuant to the Texas Public Information Act

• Advised on HIPAA health care privacy issues, including the responsibilities of a business associate to report breaches of the law promptly

• Provided advice on corporate practice of medicine restrictions in Texas and limitations under the law on which entities may accept health insurance or managed care risk

• Participated in Texas Association of Health Plans’ workgroup on prompt payment law reform, focused on the conflicts caused by lengthier grace period for payment of premium under ACA