AHLA Health Plans Contracting Handbook: A Guide for Payers and Providers (Non-Members)

Robert M. Keenan, III (Editor, Project Chair, and author of Chapter 1, Introduction: Basics of Contracting and Negotiating) is a partner with King & Spalding and advises health systems, hospitals, home health companies, pharmacy benefit management companies, pharmaceutical and medical device companies, physician organizations and managed care companies on a wide variety of federal and state regulatory matters, including health information privacy, fraud and abuse, certificate of need, licensure and managed care/insurance issues. Mr. Keenan also represents health industry clients in various transactional matters, including healthcare regulatory due diligence in connection with mergers and acquisitions, joint ventures between healthcare providers, managed care contracting, and general contracting. He has specialized experience dealing with health information privacy issues for HIPAA covered entities and business associates, as well as for device and pharmaceutical companies.

Mr. Keenan also has a particular focus advising hospitals and health systems on regulatory and structuring issues applicable to physician practice acquisitions and employment. Mr. Keenan is included in the most recent editions of The Best Lawyers In America, the Chambers USA Client's Guide to American's Leading Lawyers for Business, and Guide to the World's Leading Healthcare Lawyers. Mr. Keenan is a member of the American Health Lawyers Association (AHLA) (Health Information & Technology, Fraud and Abuse, HMOs and Health Plans, and Life Sciences subcommittees), the Health Law Section of the American Bar Association, and the State Bar of Georgia, and is a member and past President of the Georgia Academy of Healthcare Attorneys. He writes and speaks frequently on health law issues and is the Co-Editor of the AHLA's Health Plans Contracting Handbook, 6th ed. (2011).

Mr. Keenan graduated from the University of Illinois in 1985 and from the University of Georgia School of Law in 1988 where he was Executive Editor of The Georgia Law Review. Mr. Keenan served as law clerk to the Honorable Bobby R. Baldock, United States Court of Appeals for the Tenth Circuit, in Roswell, New Mexico. He began his legal career at King & Spalding, served for four years as Assistant General Counsel with Prudential HealthCare in Atlanta, and then returned to King & Spalding in 1999. He is a partner in the firm's Healthcare Practice Group.

Anne W. Hance (Co-Editor and Project Vice Chair) is a partner in the law firm of McDermott Will & Emery LLP and is based in the Firm's Washington, D.C. office. She is a member of the Health Industry Advisory Practice Group and co-chair of the Firm's Insurance/Payers Affinity Group. Anne focuses her practice on advising health insurers, health maintenance organizations, pharmacy benefit managers and other industry stakeholders on federal and state regulatory matters. She counsels clients on a broad range of issues, including health insurance market reforms enacted under the Affordable Care Act; federal health care programs, including the Medicare managed care (Medicare Advantage) Program, the Medicare prescription drug benefit (Medicare Part D), and the Medicaid Program; state insurance regulatory issues; provider and administrative service contracting; HIPAA privacy and security matters; federal fraud and abuse and compliance issues; as well as general legal and health policy issues. She has worked with health plans and pharmacy benefit managers on pharmacy benefit management contracts and related regulatory issues involving pharmaceutical pricing and benefit design and administration.

Anne frequently presents and authors articles on issues relating to Health Care Reform, Medicare Advantage, and Medicare Part D, including legislative and regulatory developments, compliance matters, and Medicare risk adjusters. She served for six years as vice-chair in charge of publications for the American Health Lawyers Association's (AHLA's) Payers, Plans and Managed Care Practice Group, and currently is serving as co-chair for the planning committee for AHLA's 2015 Institute for Health Plan Counsel and also serves on the editorial advisory board for BNA's Health Insurance Report. This is Anne's second time serving as a co-editor for the AHLA Managed Care Contracting Handbook, having worked with the authors and editors on the 6th Edition as well.

Leah B. Stewart (Co-Editor and Project Vice Chair) is a shareholder at Beatty Bangle Strama, PC in Austin, Texas, and practices in several areas of healthcare and regulatory law, with an emphasis on managed care. She represents hospitals, provider-affiliated plans, pharmacies, and other healthcare entities on a wide range of matters, including healthcare and managed care contract arrangements; regulation of healthcare providers, health plans, insurance and workers' compensation carriers; federal and state privacy issues (HIPAA); Texas legislative and rulemaking initiatives; federal and state fraud and abuse laws; Medicare Parts C and D; licensure and certification by the Texas Department of Insurance; and health care transactions. Leah is actively involved in AHLA and has served as a Vice Chair in the Payers, Plans and Managed Care Practice Group since 2011. Leah is an alum of the University of Virginia School of Law and Texas A&M University.

Matthew P. Amodeo (Chapter 2, Accountability and Collaboration-The New Paradigm in Payer-Provider Relationships) is a partner with Drinker Biddle & Reath LLP in their Albany, New York office. He focuses his practice on hospital physician Affiliation transactions, managed care contracting, accountable care arrangements and New York healthcare regulatory matters. He advises healthcare providers, ACOs and population health management companies concerning structural, operational and payment issues involved in shared savings and other types of risk arrangements with third party payers. Matthew also advises health systems regarding Federal and state Exchange related matters, the Medicare Shared Savings Program and other Medicare payment reform initiatives under the Affordable Care Act.

Adam C. Aseron (Chapter 4, Key Contract Definitions) is a founding member of Giles Aseron PLLC. Adam's principal area of practice is healthcare law, with an emphasis on transactional and regulatory matters. Adam represents physicians, hospitals, and other healthcare entities, as well as healthcare industry investors, in connection with business transactions and ventures, federal and state regulatory matters, and day-to-day operations and compliance issues. Adam regularly advises clients on managed care contracting issues. Before co-founding Giles Aseron PLLC, Adam worked for several years as a healthcare attorney with the Austin office of Vinson & Elkins L.L.P. Previously, Adam served as a judicial clerk for The Honorable Thomas B. Bennett, U.S. Bankruptcy Court for the Northern District of Alabama. Adam obtained his law degree from the University of Texas School of Law in 2006, where he graduated with high honors, was a member of the Order of the Coif, and an Associate Editor of the Texas Law Review. He also received the Robert S. Strauss Endowed Presidential Scholarship in Law, the David J. Beck Endowed Presidential Scholarship in Law, and Dean's Achievement Awards in both Civil Procedure and U.S. Law and National Security. Before law school, he received his B.B.A. with honors in banking and finance at the University of Georgia. Adam is licensed to practice law in Texas and New York.

James W. Boswell (Chapter 10, Dispute Resolution) is a litigation partner practicing in King & Spalding's Healthcare Practice Group. His practice is devoted to handling litigation and investigations on behalf of healthcare industry clients. Mr. Boswell has represented healthcare entities in administrative matters, False Claims Act lawsuits, civil litigation proceedings, and government investigations. Mr. Boswell regularly handles jury trials, administrative hearings, arbitrations and appellate arguments involving specialized healthcare issues, including managed care specifically. He received his law degree, magna cum laude, from Harvard University in 1991. Mr. Boswell joined King & Spalding in 1992 after clerking on the United States Court of Appeals for the Fifth Circuit. Mr. Boswell is a member of the Board of Directors of the American Health Lawyers Association. From 2009 to 2012, he served as Chair of the Healthcare Liability and Litigation Practice Group of the American Health Lawyers Association. In 2008, Nightingale’s Healthcare News recognized him as one of twelve "Outstanding Healthcare Litigators" nationally. Mr. Boswell is listed in Chambers USA, Super Lawyers, Best Lawyers in America, and Georgia Trend's Legal Elite.

Robin J. Fisk (Chapter 5, Payer Programs and Policies: Utilization Management and Quality Assurance) is the principal of Fisk Law Office in Ashland, New Hampshire. She advises health care providers, practitioners and managed care organizations. She drafts and negotiates managed care contracts, affiliation agreements and payment arrangements. She assists providers with coverage and payment appeals, assists insurers with licensure issues and advises on payment and regulatory compliance matters. In addition, she advises clients on general business issues such as leases and employee matters. A frequent author and speaker, Robin writes the on-line column Managed Care Contracting & Provider Payment (www.ManagedCareContracting.com) and is a contributing author to the 7th edition of the American Health Lawyer's Association's Health Plans Contracting Handbook. Robin teaches Health Law and Ethics at the MBA level and is currently the President of the board of a federally qualified health center. She is also a long time member of the American Health Lawyers Association, the Healthcare Management Association and former Chair of the New Hampshire Bar Association's Health Law Section. She graduated from Boston University School of Law a very long time ago.

Lisa G. Han (Chapter 12, Medicare Managed Care Contracting) is a partner at Jones Day. Lisa represents a wide variety of health care organizations and provides strategic and transactional and regulatory counseling with respect to their managed care operations. Lisa has significant experience in mergers, acquisitions, and restructurings of insurance companies and managed care plans; insurance holding company transactions and related regulatory filings; state insurance law, including license, products filings and insurance marketplace compliance; Medicare Advantage and Medicaid managed care plan compliance and operation; formation of ACOs and clinically integrated network and other types of network development; value-based purchasing strategies, including bundled payment, P4P, gain sharing, consumer directed health plan and other risk based programs; Health Reform Law.

Richard J. King (Chapter 6, Payment Methodologies, Including Risk-Based Payment) is a Shareholder with Stevens & Lee, P.C. He concentrates his practice in health law with emphasis on federal and state regulatory compliance and third party reimbursement, including Medicare, Medicaid and nongovernmental commercial payers. He has represented more than 100 hospitals, nursing homes and personal care facilities in state and regulatory proceedings, including survey, certification and certificate of need matters. He has appealed Medicaid and Medicare disputes and has defended clients in insurance, health care, commercial and franchise law matters. Mr. King frequently writes and speaks on a wide range of health law and policy topics and has presented before numerous professional organizations, including the Delaware Health Care Facilities Association, the Healthcare Financial Management Association, and the Pennsylvania Bar Institute. He is a former Chair of the Health Law Section of the Delaware Bar Association. Mr. King received an M.P.H., with a concentration in Health Policy and Management, from the Harvard University School of Public Health, a J.D. from the University of North Carolina School of Law, and was an Echols Scholar at the University of Virginia, where he earned his B.A. with distinction.

John M. Kirsner (Chapter 3, Antitrust Issues in Payer/Provider Contracting) is a partner in the healthcare practice group at Jones Day, resident in Columbus, Ohio. Mr. Kirsner's practice focuses on provider integration strategies, including development and ongoing legal and regulatory advice for accountable care organizations, clinically integrated networks and other provider network strategies. He also has led several engagements forming sophisticated integrated provider organizations, including establishing foundation models, professional service agreement models and loose affiliation models involving large multispecialty group practices and hospital systems. He has extensive experience with commercial ACO shared savings arrangements, assisting in the negotiation of such models with payers, as well as establishing internal distribution mechanisms. Mr. Kirsner has many years of experience with payer/provider contracting issues as well. He has written book chapters for other AHLA publications, is a co-author of a book on payer/provider contracting issues, and is a frequent national speaker and author on healthcare issues. He is a past chair of the Ohio State Bar Association Health Care Law Committee, and has been named to the Best Lawyers in America for both healthcare and insurance law since 2007, and an Ohio Super Lawyer since 2006. He is a 1992 graduate of The Ohio State University Moritz College of Law, and has two wonderful children, Eleanor (7) and Ariel (5), with his wife Lisa.

Mark S. Kopson (Chapter 9, Other Contract Provisions) is a shareholder in Plunkett Cooney's Bloomfield Hills, Michigan office and chairs the firm's Healthcare Industry Group. His practice emphasizes managed care negotiation, contracting and dispute resolution, performance/outcomes-based reimbursement and revenue cycle, as well as regulatory compliance, agency investigation response and for-profit acquisitions of non-profit providers. Mr. Kopson advises individual and institutional providers, clinically integrated networks, and managed care plans. He serves as a chair of the American Health Lawyers Association's Payers, Plans, and Managed Care Practice Group and as chair-elect of the Leadership Council of the State Bar of Michigan's Health Care Law Section. He was a chapter author of the Health Plans Contracting Handbook: A Guide for Payors and Providers, sixth edition (2011, American Health Lawyers Association), a co-author of the Managed Care Contracting chapter of the Health Law Practice Guide (2007, Thomson West), and a chapter co-author of the Representing Physicians Handbook, third edition (2012, American Health Lawyers Association). Mr. Kopson has been selected for inclusion in Best Lawyers in America (2014-2015), Michigan Super Lawyers, and Top Lawyers (2014-2015), all for health care law. He is a frequent speaker on health law topics and also serves as an arbitrator and mediator.

Kathrin E. Kudner (Chapter 13, Medicaid Managed Care) is a member of the Health Care Practice Group of Dykema Gossett in the Ann Arbor, Michigan, office. Ms. Kudner specializes in the representation of health care providers, health plans and biotechnology and life sciences companies in connection with corporate transactions, HIPAA compliance, contract review and drafting, tax exempt issues, impact of the Affordable Care Act, and FDA and clinical research related regulatory matters. Her emphasis in managed care includes managed care contracting, provider networks, including accountable care organizations, regulatory compliance, and Medicare and Medicaid plans. Since 2006, Ms. Kudner has been ranked among the top health care attorneys in Michigan by the "Michigan Super Lawyers." The Best Lawyers in America has listed Ms. Kudner for health care law since 1999.

Steven J. Lauwers (Chapter 8, Insurance Requirements and Indemnification) is a shareholder with Rath, Young and Pignatelli, P.C. and a member of the firm's executive committee. He heads the firm's Financial Institutions Practice Group and advises clients on a wide range of insurance, corporate and banking/trust company matters. Steve focuses his practice on corporate, financing, risk transfer and regulatory matters involving insurance companies, banks, trust companies and other financial institutions, healthcare organizations and government contractors. He is a nationally recognized expert on insurance law, and he represents a number of clients before the Insurance Department on a range of matters, including mergers and/or acquisitions, insurance company formation, reinsurance, licensing, market conduct, rehabilitation and liquidation, and rate and form approvals. Steve also represents a number of clients before the Banking Department on a similar range of matters. Prior to joining the firm in 2000, Steve was the Assistant Insurance Commissioner for the State of New Hampshire. In this role he acted as the General Counsel for the Department and was involved in a wide range of regulatory and transactional matters. Prior to his government service, Steve was Vice President & Counsel in the Law Department of Aetna Life & Casualty in Hartford, Connecticut where he headed both the Property/Casualty Law and Life/Annuity Law Sections of Aetna's Law Department.

Jacqueline B. Penrod (Chapter 11, Protecting Against Insolvency) practices as Senior Counsel at the AmeriHealth Caritas Family of Companies in Philadelphia, Pennsylvania. A graduate of the James E. Beasley School of Law at Temple University, she served as the Editor-in-Chief of the Temple Law Review during the 2001-2002 academic year and as a law clerk for the Honorable Gene E.K. Pratter in the United States Court for the Eastern District of Pennsylvania from 2004 until 2006. In addition to her Juris Doctor degree, Ms. Penrod has a master's degree in Business Administration with a concentration in Finance. For approximately ten years prior to attending law school, Ms. Penrod worked as a business manager and consultant in the health care industry, specializing in the area of managed care. Her professional experience includes working at a national accounting firm as a financial analyst for a small Medicaid health maintenance organization and as director of Managed Care for a 500-bed inpatient hospital.

Michael F. Schaff (Chapter 7, Term and Termination Provisions) is the Chair of the Corporate and Healthcare Departments and shareholder of Wilentz, Goldman & Spitzer PA. For the American Health Lawyers Association, Mr. Schaff is a former member of the Board of Directors (2006-12), Executive Committee (2010-2012), Finance Committee (2011-2012), Chair of Practice Groups (2010-2012) and currently the Co-Chair of AHLA's Physician & Hospital Law Institute. Mr. Schaff is a frequent author and lecturer, and has spoken on numerous national teleconferences, webinars and seminars and is quoted frequently in national publications. Mr. Schaff is currently on the Advisory Board of BNA's Health Law Reports and is the Chair of the Editorial Committee of the New Jersey Lawyers Magazine. Mr. Schaff is listed in Best Lawyers of America (2003-2014), New Jersey Super Lawyers (Top 100, 2007-2014) and Chambers USA (Band 1 Healthcare, 2011-2014).

Adam C. Varley (Chapter 8, Insurance Requirements and Indemnification) is a shareholder of the firm and a member of the Business and Finance, Financial Institutions and Healthcare Practice Groups at Rath, Young and Pignatelli, P.C. He focuses his practice on insurance, banking, healthcare and corporate and business law. Adam assists insurance companies, trust companies and financial institutions, healthcare providers and a wide range of other businesses with regulatory, licensing, transactional and compliance issues. He regularly represents clients before the New Hampshire Insurance and Banking Departments on a variety of matters. Adam also advises clients on a range of issues with respect to health insurance and other employee benefits plans, including extensive work with clients on issues related to the implementation of the Affordable Care Act. Prior to joining the firm in 2007, Adam practiced law in the Healthcare Group at the Albany office of Greenberg Traurig, LLP where he represented managed care companies and other insurers on a wide range of regulatory issues. During law school, Adam worked at the United States Department of Justice and the National Treasury Employees Union in Washington, DC, and the Suffolk County District Attorney's Office in Boston, Massachusetts.