Primary Areas of Practice

Contract Drafting/Editing/Negotiation

  • Provider contracts with managed care organizations (“MCOs”), including value-based, incentive       arrangements

  • MCO delegation agreements with behavioral health, vision, dental, disease management, nurse hotline and PBM subcontractors

  • Telemedicine, telehealth, and delegated credentialing agreements 

  • Third-party administrator and utilization review services agreements

  • Management services and health care consulting agreements

  • Settlement agreements between MCOs and health care providers

  • Single-case agreements between MCOs and non-network providers


Operational and Regulatory Compliance

  • Review and draft comments to Medicaid managed care, Medicare Advantage and Medicare-Medicaid Plan (“MMP”) contracts between MCOs and state Medicaid agencies and/or CMS

  • Review and draft comments to state and federal regulations affecting Medicaid, SCHIP, Medicare, MMP, the Exchange/marketplace plans and general health care and insurance matters

  • State licensure – compliance matters, filings and administrative penalty matters including drafting of corrective action plans

  • Policy and procedure review and revision for compliance purposes, including HIPAA privacy and security policies and business associate requirements

  • Interpretation and education on Medicaid, HMO, health insurance and general health laws, from both state and federal sources


Health Plan Coverage Documents and Provider Network Filings

  • Draft and edit on- and off-Exchange evidences of coverage and certificates of coverage, group policy forms, and ancillary documents for HMOs and PPOs

  • Draft Medicaid and Medicare member handbooks and provider manuals

  • Prepare and file service area expansion applications

  • Develop and file network adequacy access plan materials


Interface with State and Federal Agencies

  • Draft and file letter briefs to protect company information requested in an Open Records request submitted to a state or federal agency

  • Prepare responses to member, provider and legislative complaints filed against the MCO

  • Attend stakeholder and workgroup meetings at the Texas Health and Human Services Commission, the Department of Aging and Disability Services, and the Texas Department of Insurance

Copyright 2019 by Susan M. Erickson, Esq.