Negotiating Managed Care Agreements With Health Plans: Key Provisions, Anticipating Areas of Dispute, Court Treatment

Mr. Malone helps health care organizations navigate the most complex regulatory, transactional, and strategic issues in managed care and delivery system reform. Managed care organizations, provider groups, value-based enablement companies, and trade associations seek his advice on matters involving, among other things: Medicare Advantage, SNPs, Medicaid managed care organizations, commercial insurers, participants in the Program of All-Inclusive Care for the Elderly (PACE), Medicare Shared Savings Program and ACO REACH entities, self-funded group health plans, third-party administrators, and pharmacy benefit managers. With a distinguished body of work on dual-eligible delivery systems and the Mental Health Parity and Addiction Equity Act, Mr. Malone is also a trusted counselor on value-based payment arrangements, risk-bearing structures, and corporate governance for integrated care models. His practice bridges regulatory compliance, business strategy, and dispute resolution, allowing clients to operate confidently in a fast-evolving health care environment. Before entering private practice, Mr. Malone served in senior policy roles at the CMS, where he developed financing and delivery models for dual-eligible beneficiaries, advanced PACE expansion, and shaped Medicaid policy for medically frail populations. He is a frequent speaker and author on managed care law and policy. He also serves as an accreditation reviewer for URAC’s Mental Health Parity Accreditation Program, assessing compliance with federal parity requirements and industry best practices, and teaches Managed Care Law & Policy as an adjunct professor at The George Washington University Law School.

Mr. Mitchell works with healthcare payors and providers to meet the full spectrum of their managed care and reimbursement arrangement needs. He works closely with managed care organizations, insurers, hospitals and health systems, academic medical centers, and other organizations both large and small to negotiate and draft managed care agreements, network participation agreements, and more. Mr. Mitchell is experienced across a variety of arrangements and models, including fee-for-service, value-based care, bundled payment, shared savings and shared loss models, gainsharing and capitation arrangements.