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Payers, Plans, and Managed Care
Practice Group
Todd M. Ebersole, Chair / Anne W. Hance, Vice Chair of
Publications / Mark Kopson, Vice Chair of Membership /
Leah Stewart, Vice Chair of Educational Programs / Brian
Stimson, Vice Chair of Research and Website/ Jim Wolf,
Vice Chair of Strategic Activities / Wilson M. Acevedo,
Managed Care Contracting Affinity Group (MCC AG) Leader /
Kathy S. Ghiladi, MCC AG Leader / Elizabeth Lippincott,
Medicare Advantage and Part D (MA/Part D) AG Leader /
Janice Ziegler, MA/Part D AG Leader / Kirk Nahra, Health
Plan AG Leader / Xavier Baker, Email Alert Co-Chair /
Robert Slavkin, Email Alert Co-Chair / Alan Bloom,
Discussion List Moderator
A Lesson in ROI
Q:
If you invested 96.15¢ per week,
in 2013-2014, what did you
receive?
(a)
(b)
(c)
(d)
9 grande lattes
10 Sunday papers
1 dinner at Olive Garden
Everything listed below from the
Payers, Plans, and Managed Care
Practice Group (PPMC PG):
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23 Webinars, Roundtables, and Virtual
Luncheons delivering invaluable
knowledge, insight, and networking
The second annual Institute for Health Plan
Counsel
Two in-person luncheon presentations
featuring experts in their fields
Three dynamic AGs delivering content
available only to PPMC PG members:
o Health Plan
o Managed Care Contracting
o Medicare Advantage and Part D
A Managed Care Contracting Toolkit with
comprehensive resources for plan and
provider counsel—including State Law links
and a comprehensive Medicare Parts C and
D appendix
Two newsletters with in-depth articles on
real-world topics and issues, including Health
Insurance Exchanges
Seven downloadable tutorials that let PPMC
PG members get up to speed on substantive
topics anywhere and anytime
Multiple email alerts every month on
breaking news and hot topics
Frequent Twitter updates specific to PPMC
issues by PPMC PG members
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Two Member Briefings on Medicaid Managed
Care Contract Bid Disputes and State Fair
Procedure Rights for Excluded Providers
A Health Care Reform Litigation Resource
Center
Stimulating Discussion List debates
And, most importantly, the opportunity to tell
your Practice Group exactly what you want—
and actually get it!
Broader Coverage of the PPMC industry
including Pharmacy, Pharmacy Benefit
Management, Specialty Plans, and Plan Counsel
Under the leadership of PPMC PG Chair Todd
Ebersole, the PPMC PG has actively and
successfully “expanded its tent” through
more sub-specialty programming in these
and other growing areas of interest. Our
all-time high membership of 980 PPMC PG
members is a testament to the PPMC PG’s
commitment to consistently produce and
deliver high-quality programming relevant
to all facets of the managed care industry,
including our members in the pharmacy,
pharmacy benefit management, and specialty
plan areas. If you want special-knowledge
programming, you have a home in the PPMC PG.
Educational Programs
Under the leadership of Vice Chair of Educational
Programs Leah Stewart, the PPMC PG has provided
outstanding educational programs in budget-friendly
Roundtable Discussion and Webinar formats. Since
July 2013, the PPMC PG sponsored or co-sponsored the
following educational programs:
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Plan-Provider Managed Care Contracting
Webinar Mini-Series: A Blockbuster in the
Making:
o The Premiere—Nuts and Bolts
o Episode 2—Hot Topics in Medicare PlanProvider Managed Care Contracting
o Episode 3—Hot Topics in Medicaid PlanProvider Managed Care Contracting
o Episode 4—Hot Topics in Commercial
Plan-Provider Managed Care
Contracting
o The Finale—Current Compensation/
Reimbursement Issues in Plan-Provider
Managed Care Contracting
Managed Care Landmines: Emerging FCA Risks
under ACA
Physician Organizations Bootcamp Webinar
and Roundtable Series:
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Educational Programs (continued)
Part V: Transactions—The Nuts and
Bolts of Documenting the Transaction
o Part VI: Integration in Medical Staff
o Part VII: Roundtable: War Stories—
Point/Counterpoint from Attorneys
Health Care Fraud and Abuse Bootcamp:
o Part VI: Trends in Government
Enforcement
Innovative Pediatric Hospital/Provider and
Payer Partnerships
Dispute Resolution in Health Care Forum:
o Part I: Keeping Health Care Disputes
out of Court and the Public Eye
o Part II: Exercising Foresight—General
Issues in Drafting Agreements to
Arbitrate Health Care Disputes
o Part III: Exercising Due Care—
Specialized Areas in Drafting
Agreements to Arbitrate Health Care
Disputes
o Part IV: Advocating Effectively in Health
Care Arbitrations
o Part V: Advocating Effectively in Health
Care Mediations
o Part VI: Roundtable: The Essential Role
of In-House Counsel in Resolving Health
Care Disputes
Fraud and Abuse Basics Bootcamp Series:
o Part I: Federal Anti-Kickback Statute
Advising Nonprofit Providers: What All Health
Care Lawyers Need to Know about Tax:
o Part IV: State and Local Tax-Exemption
Issues
o Part V: Issues for Tax-Exempts as
Employer
Unlocking the Promise of Anonymized Health
Care Data: Leveraging Compliance-Based DeIdentification Methods to Drive Better Health
Care Outcomes
Risk Adjustment Roundtable: Key Standards,
Developments, and Risks in Medicare
Advantage and Beyond
Roundtable on New Proposed Medicare
Advantage and Part D Rules
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Luncheon Meeting Programs
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At the 2013 Annual Meeting in San Diego, CA:
“Planning for 2014: An Update on Legal and
Policy Issues Related to Health Insurance
Exchanges”
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At the Institute for Health Plan Counsel:
“Narrow Plans, Broad Issues: Real World
Advice for Specialty Managed Care”
Coming up at the 2014 Annual Meeting in
New York, NY: Back to the Future: An Update
on Narrow Networks, Network Adequacy
Litigation, and Related Issues
Publications
Vice Chair of Publications Anne Hance again led
the PPMC PG’s production of outstanding publications
since July 2013, including:
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PPMC PG Fall 2013 Newsletter focused on
the health insurance exchanges with articles
such as “Understanding Tax Issues that Affect
Consumers Using Exchanges,” “Prescription
Drug Benefit Considerations for Health
Insurance Exchanges,” and “Premium
Stabilization Programs under the ACA:
Financial Protection with Strings Attached.”
Member Briefings: “An Overview of Medicaid
Managed Care Contract Bid Disputes as the
Medicaid Expansion Becomes a Reality” and
“Survey of State Fair Procedure Rights
Triggered by Excluding Providers from Health
Care Networks.”
Email Alert Program: A series of summaries
and analyses of breaking developments,
including government issuances and case law,
affecting managed care.
Volunteer authors are needed for 2014-2015.
Constant legal developments present great
opportunities to share your knowledge on
topics of interest to other PPMC PG members.
Affinity Groups (AGs)
PPMC PG Vice Chair of Strategic Activities Jim Wolf
has deftly coordinated the missions and growth of PPMC
PG’s three AGs. The AGs play an increasingly important
role in the operations of the PPMC PG and exemplify the
PPMC PG’s efforts to strategically meet both the general
and specialized needs of the PPMC PG members.
Remember: Only PPMC PG members can
participate in our terrific Affinity Groups!
Health Plan AG
Under the leadership of Chair Kirk Nahra, Health Plan
AG membership grew by 90% this year by
providing, obtaining, and facilitating information
exchange and best practices among lawyers who
represent health plans or who work at health plans and
the unique issues they face. If you are among the
growing subset of PPMC PG’s members who represent
health plans as in-house or outside counsel, this is an AG
you need to join.
Managed Care Contracting AG
Under the leadership of Co-Chairs Kathy Ghiladi and
Wilson M. Acevedo, the Managed Care Contracting
AG membership grew by more than 117% this year
by focusing on issues related to contracts involving
managed care organizations. Example: the AG’s online
Managed Care Contracting Toolkit with sample clauses
for virtually all key contract sections (including providerfriendly, plan-friendly, and neutral) plus Appendices on
Managed Care Litigation, Health Insurance Portability
and Accountability Act (HIPAA) Business Associate
Agreements, State Law Contracting Links, and Medicare
Parts C and D Contracting Links. The Toolkit provides
valuable contracting resources for PPMC PG
members representing plans or providers. We
welcome your content suggestions and new
contracting links.
Medicare Advantage and Part D AG
Under the leadership of Co-Chairs Janice Ziegler and
Elizabeth Lippincott, the Medicare Advantage and
Part D AG membership grew by more than 153%
this year. How? By serving as the forum for the
exchange of information, ideas, and best practices
among the community of Medicare Advantage and Part D
lawyers. Programming highlights included a roundtable
discussion on “New Proposed Medicare Advantage and
Part D Rules” and a ground-breaking Virtual Luncheons
series that provides unique networking opportunities for
plan lawyers in addition to substantive education.
Email Alerts on Breaking News and Hot Topics
PPMC Email Alert Co-Chairs Rob Slavkin and Xavier
Baker released multiple email alerts each and every
month, within days of new developments in the managed
care industry. Email alerts covered a wide range of
topics, including an Annotated Listing of Federal
Guidance Related to Individual and Small Group Plan
Markets and an Annotated Table of Contents for the
Medicare Advantage and Part D Proposed Rule. We are
seeking authors to help prepare these short
summaries of important developments in the
managed care industry, and writing an email alert
is a terrific way to “dip your toes” into active
participation in the PPMC PG.
Tutorials and Tweets
Vice Chair of Research and Website Brian Stimson
continued to champion the PPMC PG’s technological
progress. The PPMC PG website now delivers additional
value with a library of introductory-level MP3 tutorials on
topics such as HIPAA, Prompt Payment, and Medicare
Parts C and D. These fantastic resources are available to
our members anywhere and at any time. We are
seeking volunteers to present additional
introductory-level tutorials for younger
lawyers and lawyers new to various specialties
or substantive areas.
PPMC PG also expanded its social media presence
through its Twitter handle, @AHLA_PPMC, which it uses
to alert members to new legal developments and
upcoming PPMC programs. Follow us on Twitter—
@AHLA_PPMC—for instant news and right-now
commentary. Love all things tech? Why not join
our team of Twitter volunteers?
Health Care Reform Litigation Resource Center
PPMC PG developed the original Health Care Reform
Litigation Resource Center for AHLA’s Health Care
Reform Educational Task Force. The Resource Center
provides easy access to the key pleadings, briefs,
opinions, and other documents filed in lawsuits
challenging the Affordable Care Act. It offers one-stop
access to: the appellate briefs filed by litigants and
interested parties with the U.S. Supreme Court; filings
from legal challenges to various aspects of the ACA;
and third-party resources, such as the ACA Litigation
Blog. The PPMC PG is updating the Resource Center as
ACA litigation continues.
PPMC PG Members Play a Direct Role in
Determining PPMC PG Products and Programs
Vice Chair of Membership Mark Kopson led our
efforts to grow and maintain membership by continually
discovering what our members want and need from their
PPMC PG membership—and giving it to them! Through
annual in-depth member surveys and feedback
solicitations for every program, we give our members
the opportunity to tell us exactly what they want and
need from their PG. Our all-time high membership of
980—including 96 new members since July 1,
2013—demonstrates that we listen and—most
importantly—deliver the maximum benefit for your
$50 annual PG dues.
Let us know how you feel we are doing and what else we can do for you. Better yet, get involved! We
welcome health lawyers of all ages and experience levels and believe that everyone has value to
contribute. Regardless of how much or little time you can or wish to commit, we welcome your
participation! Contact any member of the PPMC PG leadership team or email us at:
pgs@healthlawyers.org. Don’t wait. Do it today!
Payors, Plans and Managed Care Practice Group
2013-2014 PPMC PG Leadership Team
Todd M. Ebersole, Chair
Anne W. Hance, Vice Chair of Publications
Mark Kopson, Vice Chair of Membership
Leah Stewart, Vice Chair of Educational
Programs
Brian Stimson, Vice Chair of Research and
Website
Jim Wolf, Vice Chair of Strategic Activities
Alan Bloom, Discussion List Moderator
Wilson M. Acevedo, Managed Care Contracting
AG Leader
Kathy S. Ghiladi, Managed Care Contracting
AG Leader
Elizabeth Lippincott, MA/Part D AG Leader
Janice Ziegler, MA/Part D AG Leader
Kirk Nahra, Health Plan AG Leader
Xavier Baker, Email Alert Co-Chair
Robert Slavkin, Email Alert Co-Chair
To learn more and/or join the PPMC PG for just $50, please call
(202) 833-1100 (prompt #2) or visit www.healthlawyers.org/PracticeGroups.