ERISA Compliance in Direct Contracting for Healthcare: Challenges for Employers and Providers

Ms. Morgan specializes in complex multi-state health insurance and health care regulatory challenges, drawing on more than fifteen years of experience both in-house and at top tier international law firms. She is a well-known expert in payor/provider issues and is adept in the intricacies of the Affordable Care Act (ACA) and state health insurance and managed care laws, and the interplay of the two. Additionally, Ms. Morgan has been part of industry-defining changes in digital health, data transparency and the post-CAA fiduciary landscape. She has advised health insurance and managed care clients on a broad range of regulatory issues, including state and federal mandated benefits; state and national health care reform; group health laws (e.g., extra-territorial applicability, withdrawal from group business); joint ventures; HIPAA and state conversion and continuation of coverage provisions; state privacy laws; utilization review requirements; company licensing; broker and agent issues; and applicability and interpretation of other relevant statutes and regulations. Ms. Morgan also provides regulatory advice regarding non-traditional healthcare models to third party administrators, consulting companies, and financial institutions, including negotiating with state insurance regulators to obtain insurance license exemptions for such models. She has a stellar record of positive outcomes when representing clients before state regulators in investigations and enforcement actions.

Mr. Shillcutt has deep experience in the areas of behavioral health, government and commercial reimbursement, and managed care due to his work at the Centers for Medicare & Medicaid Services (CMS), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Centers for Disease Control and Prevention (CDC).

Health care providers, payers, digital health companies, and investors call on Ms. Worthen for legal and strategic advice as they navigate complex regulatory and business challenges in the continuously evolving health care delivery and reimbursement landscape. Her practical guidance enables clients across the health care ecosystem—health systems, hospitals, physician practices, digital health companies, behavioral health providers, third-party administrators, health plans, and investors—to implement both short- and long-term strategies that align with their organizational goals. Ms. Worthen possesses a wealth of experience working on matters concerning Medicare reimbursement, Medicare Advantage, participation in CMS Innovation Center payment models, managed Medicaid, managed care contract negotiations, and value-based payment arrangements with commercial payers, self-insured employers, and Medicare Advantage plans. She provides counsel on the regulatory, operational, and financial considerations necessary for maneuvering through the changing payment environment, including various forms of risk-based payment models, price transparency, revenue cycle and payment integrity, clinically integrated network development and value-based enterprise models, risk adjustment, and provider compensation arrangements. Beyond her health care practice, Ms. Worthen provides ERISA counsel to employers regarding their defined benefit and defined contribution retirement plans, as well as self-insured and fully insured welfare benefits plans, and has represented clients in government audits conducted by the IRS and the U.S. Department of Labor.