Health Insurance Industry Partners (PBMs, TPAs, DMPOs and URAs)
Legal counsel delivering value and experience for pharmacy benefit managers (PBM), third-party administrators (TPA), utilization review agents (URA) and discount medical plan organizations (DMPO)
Capabilities at a glance
- A dedicated team of experienced attorneys who lead the industry in representing health coverage payor entities and their partners, including PBMs, TPAs, URAs and DMPOs.
- Legal support built on understanding each client’s needs, the business of health care in general and evolving legal requirements in all 50 states.
- Serving as comprehensive regulatory counsel, we help keep you up to speed on licensing, reporting and compliance requirements across the country.
Practical legal and strategic guidance suited to your business needs
In addition to representing health insurance companies and self-funded plans, our firm’s Health Law attorneys represent entities hired by or under contract with health coverage payors to provide valuable services related to claims processing and health care utilization. This includes PBMs, TPAs, URAs and DMPOs. Providing such guidance efficiently requires not only understanding each client’s unique business needs, but also understanding the business of health care generally. Specific to PBMs, TPAs, URAs and DMPOs, our experience includes licensing, reporting and compliance requirements in all 50 states, managing business transactions such as formations, mergers and acquisitions, and designing and implementing clinical integration programs.
Extensive experience and knowledge of PBMs, TPAs, URAs and DMPOs
What sets our Health Insurance Industry Partners team apart is our knowledge of the entirety of the legal landscape affecting PBMs, TPAs, URAs and DMPOs. This area is rapidly evolving, and our team engages in ongoing analysis and evaluation of state and federal laws affecting these entities. We have the depth and breadth of industry knowledge along with years of experience resolving the day-to-day legal and strategic business issues confronting our clients. Over decades, we have built relationships with regulators that allow us to successfully advocate for our clients’ interests; this often enables us to influence proposed statutes and regulations before they go into effect. Our clients receive this level of experience and knowledge in a practical, proactive and cost-effective manner.
Experience
- Evaluating state laws pertaining to PBM, TPA, URA and DMPO requirements and developing corresponding guidance documents.
- Analyzing state-by-state requirements for PBM, TPA, URA and DMPO licensure, including tracking legislative trends and regulatory developments.
- Developing corporate governance and administrative documentation, including operating agreements, company policies and procedures, conflict of interest review frameworks and more.
- Designing and implementing programs for clinical integration.
- Executing formations, mergers, acquisitions and regulatory actions for PBM, TPA, URA and DMPO entities.
- Providing guidance on unique PBM, TPA, URA and DMPO structures and negotiations.
- Complying with antitrust and insurance laws.
- Complying with laws related to data sharing, aggregation and analytics, including the development and negotiation of vendor agreements.
- Complying with regulations, including fraud and abuse issues such as the Stark Law, Anti-Kickback Statute and False Claims Act.
- Interfacing with regulators on new and existing laws impacting PBM, TPA, URA and DMPO businesses.
Successes
- Served as lead counsel on an internal reorganization, where our team determined and analyzed applicable PBM laws and regulations across the majority of states related to change of ownership requirements and PBM licensure. We assisted our client in identifying and preparing the appropriate state regulator notifications and forms.
- Outlined for our client the regulatory landscape for PBMs and TPAs across all 50 states, including flagging the distinctions and overlaps between PBM and TPA licensure requirements. We further analyzed state maximum allowable cost (MAC) reporting related to PBM and TPA licensure requirements and advised the client accordingly.
- Provided utilization review services to a URA client for Medicare Advantage, ensuring our client complied with the state laws governing contracts in all 50 states. Where necessary, we helped our client gain multiple licensures in other states and ensure ongoing compliance.
- Advised a multi-state URA client on how dozens of new state laws would impact its business, including identifying the steps necessary for our client to comply with the laws and interfacing with regulators regarding the laws and our interpretation of them.
- Assisted a DMPO with monitoring and evaluating state regulations, guidance and enforcement actions applicable to the client’s medical, dental and pharmacy discount health program.
- Advised a DMPO client on contracting with insurers and employers wishing to integrate discount health programs into their customer offerings and usual and customary pricing issues.
