Health & Life Sciences

Health Insurance Industry Partners

Health Insurance Industry Partners: Representing Pharmacy Benefit Managers (PBMs), Third-Party Administrators (TPAs), Utilization Review Agents (URAs), and Discount Medical Plan Organizations (DMPOs)

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 healthcare utilization. This includes Pharmacy Benefit Managers (PBMs), Third-Party Administrators (TPAs), Utilization Review Agents (URAs), and Discount Medical Plan Organizations (DMPOs).

We understand the legal landscape for PBMs, TPAs, URAs, and DMPOs is rapidly evolving, and our team is equipped to advise clients on current and emerging licensing, reporting and compliance requirements in all 50 states.

Our work in this area includes:

  • 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 for PBM, TPA, URA, and DMPO businesses
  • 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 analytic, 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/or existing laws impacting PBM, TPA, URA, and DMPO businesses

In just the last few years, our Health Law attorneys have handled numerous matters for PBMs, TPAs, URAs, and DMPOs. Below are a few representative examples to illustrate the type of work we do for these clients.

Pharmacy Benefit Manager (PBM) & Third-Party Administrator (TPA) Representative Matters

  • For a client undergoing an internal reorganization, our Health Law attorneys determined and analyzed applicable PBM laws and regulations across the majority of states related to change of ownership requirements and PBM licensure. We assisted the client in identifying and preparing the appropriate state regulator notifications and forms necessary to effectuate such changes.
  • Our Health Law attorneys assisted a client in outlining the regulatory scheme 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.

Utilization Review Agent (URA) Representative Matters

  • When a URA client was awarded a contract with an insurance company to provide utilization review services for Medicare Advantage in 50 states, our Health Law attorneys helped our client review and comply 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.
  • Our Health Law attorneys advised a multi-state URA client on how dozens of new state laws would impact their 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.

Discount Medical Plan Organizations (DMPO) Representative Matters

  • Our Health Law attorneys 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.
  • We provided counsel to 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.
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