2022 Employer Compliance Reboot: The Buck Stops with You!
This is a NEBGH Members only event. If you are interested in attending and not a member, please contact Jen at email@example.com
The new year brings new healthcare compliance requirements for employers.
You need to be working with vendors to collect information, take action and respond to demands for transparency. This includes:
- Removal of gag clauses in contracts with health plans and other vendors;
- Disclosure of compensation to PBMs, TPAs and other vendors;
- Disclosure of prescription drug pricing including rebates and fees;
- Adherence to mental health parity requirements.
The buck stops with you!
Experts from Epstein Becker Green tell you what you need to know now.
Helaine I. Fingold
When clients need help understanding the federal and state regulation of health insurance, and identifying and addressing related barriers and opportunities, they turn to Helaine Fingold. Clients benefit from Helaine’s experience working at both the Centers for Medicare & Medicaid Services and the Medicare Payment Advisory Commission (MedPAC), which has given her keen insight into how regulators interpret and apply the laws, regulations, and related administrative processes regarding Medicare, Medicaid, and commercial insurance.
Her clients range from small start-ups to large corporate entities with multiple subsidiaries. They include Medicare Advantage, PACE, Medicaid, and other managed care plans; provider entities; vendors to providers and managed care companies (including administrative support entities, providers of software and online services, agents/brokers/field marketing organizations, and advertising/marketing entities).
Helaine’s practice focuses largely on the regulation of Medicare managed care (including Medicare Advantage, Part D, dual eligibles, PACE, demonstrations), Medicaid managed care, commercial managed care products (including surprise billing), and behavioral health (including mental health parity).
Helaine helps clients:
- understand and address state licensure rules that apply to their business;
- develop and submit Medicare Advantage, Qualified Health Plan, and other managed care applications for qualification;
- respond to deficiencies in Medicare Advantage applications;
- appeal the denial of a Medicare Advantage application;
- challenge and get withdrawn federally issued compliance notices for allegedly failing to comply with Medicare Advantage regulations and guidelines;
- identify and correct noncompliance with Medicare managed care laws and regulations;
- identify health regulatory compliance risks in potential investments through due diligence reviews;
- understand applicable rules, and appeal Medicare star ratings; and
- understand and interpret the new federal law on surprise billing, including areas for potential regulatory governance.
Before building her private practice, Helaine gained 20 years of experience in the federal government: 13 years at CMS, working on Medicaid, Medicare Advantage/Part D, and ACA implementation, and seven years at MedPAC. During her time at CMS, she was part of the team that implemented the Medicare Advantage program prior to its rollout in 2006. She also worked with the team that implemented the Affordable Care Act requirements applicable to federal and state health care marketplaces, qualified health plans, and individual and small group commercial insurance. Helaine’s government experience also included serving as General Counsel for the Medicare Payment Advisory Commission.
Kevin J. Malone
KEVIN J. MALONE is a Senior Counsel in the Health Care and Life Sciences practice in the Washington, DC, office of Epstein Becker Green and a Strategic Advisor in the firm’s affiliated consulting practice EBG Advisors. Mr. Malone provides regulatory and strategic guidance related to health care financing law and policy at both the federal and state levels, with a particular focus on Medicaid, Medicare, behavioral health, long-term care, and managed care.
In addition to serving some of the largest companies in the health care industry, he also works with start-ups, regional and local health care companies, trade associations, and state and local governments. He joined Epstein Becker Green in 2016 after six years in health care financing policy roles at the U.S. Department of Health and Human Services, most recently with the Centers for Medicare & Medicaid Services (CMS).
Mr. Malone’s representative engagements include:
- Serving as a secunded general counsel for a regional health plan with responsibility for managed care and government program matters
- Serving as acting general counsel for a national laboratory network benefit management and technology company
- Developing and serving as program manager for the nation’s first third-party commercial accreditation program assessing insurers’ capacity to comply with the requirements of the Mental Health Parity and Addiction Equity Act (federal Parity law). As part of this role, Mr. Malone developed the nation’s first enterprise-software solution for insurers and managed care entities’ parity compliance
- Serving as outside counsel to regional and national health insurers and managed care companies on compliance with:
- federal Parity law
- the Medicare Advantage program
- Medicaid managed care and managed long-term care programs
- the Programs of All Inclusive Care for the Elderly (PACE)
- state insurance and utilization review laws
- state and federal laws and programs governing value-based reimbursement
- Serving as strategic advisor and outside counsel to multiple national behavioral health medical specialty societies on the development and deployment of behavioral health clinical guidelines, intellectual property, and transactional matters
- Serving as strategic advisor and outside counsel to a quasi-public Medicaid pre-paid inpatient health plan (PIHP) providing managed care business strategy, government relations, and legal representation covering transactional and compliance matters in an ongoing redesign of the state’s Medicaid delivery system
- Serving as outside counsel to a multi-state, for-profit PACE company
- Serving as outside counsel to multiple national telemental health companies on state law compliance, third-party payment, and coverage compliance and negotiations
- Providing strategic counseling and transactional support to private equity and venture capital firms and other potential investors in managed care, behavioral health, and long-term care industries
- Representing hospitals and health systems in value-based contract negotiations and regulatory disputes with major national payors
- Advising states and trade associations on the design and implementation of Medicaid health delivery systems, especially those targeting Medicare-Medicaid dual-eligible beneficiaries
Prior to joining Epstein Becker Green, Mr. Malone served as a Health Insurance Specialist with the duals office, where he was the federal lead for implementing demonstration programs that aim to integrate the financing and delivery of Medicaid and Medicare benefits for dually-eligible beneficiaries in Illinois, New York State, and Washington State. Mr. Malone was a lead in the development of a new federal demonstration model for individuals with disabilities, based on the PACE model, expanding the model of care to new populations. Previously, Mr. Malone worked with the Disabled and Elderly Health Programs Group at CMS, developing a new policy for the identification and counseling of the medically frail within the Medicaid Expansion population.
As a Public Health Analyst with the Substance Abuse and Mental Health Services Administration (SAMHSA) prior to joining CMS, Mr. Malone managed multiple multimillion-dollar federal procurements and led the agency’s efforts to help substance abuse and mental health treatment providers implement advanced contracting, billing, and care coordination practices. In addition, he spearheaded SAMHSA’s efforts at public and private insurance enrollment following the enactment of the Affordable Care Act.
Before joining HHS, Mr. Malone served as a Peace Corps volunteer in Zambia, where he founded the nation’s first male-focused domestic violence prevention project.