The Law Office of Susan M. Erickson, PLLC
Based in Austin, Texas, The Law Office of Susan M. Erickson provides high-quality legal services in the areas of managed care, Medicaid managed care, Medicare Advantage plans, health insurance regulatory and general health law.
THE FIRM
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 30 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 Managed Care Manuals and submitted written comments and suggested revised language to HHSC
• Prepared Health Insurance Marketplace product, service area, and network filings for 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 on litigation matters, including by serving as a subject matter expert on Medicaid and on MCO business practices
• Analyzed legislative bills and prepared memoranda for senior leadership to describe the bills’ anticipated impact on the company’s lines of business
• Prepared the company’s medical directors for participation in Medicaid Fair Hearings
• Managed the proceedings of pre-termination provider appeal panel hearings.
• Oversaw Stark Law-related and other conflict of interest reviews for provider contracting teams.
• Key member of team that drafted and prepared RFP responses submitted to HHSC over an 8-year period for Medicaid/CHIP contracts.
• Launched the compliance program for the STAR Health (Foster Care) Medicaid managed care contract 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
Contract Drafting and Negotiation Experience
Drafting and negation of:
• Contracts with health plans' dental, behavioral health, vision, disease management, pharmacy benefit management (PBM), and medical transportation subcontractors
• Provider participation agreements between health plans/payors/TPAs and health care providers and provider entities, including physicians, hospitals, independent practice associations, ACOs, and ancillary providers
• Health care contracts with third party vendors, including EVV (electronic visit verification) providers, health and wellness coaching providers, HEDIS data collectors, credentialing verification organizations, payment integrity auditors, and claims review companies
• Confidentiality and non-disclosure agreements and HIPAA business associate agreements
• Settlement and release of liability agreements between health plans, providers and third party vendors
• Shared risk, provider incentive plans and other value-based contracting addenda to standard physician and provider participation agreements
General Health Law and Managed Care Experience
• Serve as retained outside counsel for health plans, health insurance companies and health care providers on variety of state and federal regulatory, contractual and transactional matters
• Steer 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.
• Submit and receive 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
• Submit letter briefs on rule-making initiatives to CMS, to HHSC; and to TDI.
• Successfully defeat numerous open records requests for clients’ confidential information sought via requests submitted to state agencies pursuant to the Texas Public Information Act
• Advise on HIPAA health care privacy issues, including the responsibilities of a business associate to promptly report breaches
• Provide advice on corporate practice of medicine restrictions and regulations governing the acceptance of health insurance or managed care risk