MANAGED CARE Disputes and Litigation
May 1–2, 2025 | Embassy Suites by Hilton Chicago Downtown Magnificent Mile, Chicago, IL
Be part of the only MCO-specific conference for the health care industry’s legal community.
Distinguished Co-Chairs
Korey Harvey Vice President & Deputy General Counsel Blue Cross and Blue Shield of Louisiana
Alex Lucas Partner Reed Smith LLP
A Special Fireside Chat on MCOs in the Public Eye
Renee Delphin-Rodriguez Chief Legal Officer & General Counsel SCAN
Engage with Top In-House Counsel from:
Aetna/CVSHealth
Blue Cross and Blue Shield of Louisiana Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma & Texas Cigna Healthcare Elevance Health SCAN
What’s New for 2025
ĉ Managed Care State of the Union: The Politics and Policy of MCOs under a New Administration
ĉ Unpacking Loper Bright for the MCO Industry and Adjusting to a Post-Chevron World
ĉ How MCOs Can Leverage AI to Streamline Processes While Avoiding Regulatory Pitfalls
ĉ MCOs in the Public Eye: Improving Transparency and Public Perception
ĉ Mental Health Parity: Examining the Latest Rules, Challenges, and Confusion
Supporting Sponsors Associate Sponsor
At the dawn of a New Administration, the U.S. health insurance industry finds itself in the middle of a public relations crisis.
Recent events have precipitated a wave of cutting criticisms over plan coverage and the denial of patient claims. Time will tell what, if any, reforms are proposed under Trump 2.0 in response to concerns over plan practices.
In the year ahead, MCOs must work their way across a tightrope.
Plans will need to prepare to defend themselves in this new era of heightened public scrutiny because growing sentiments of anger and distrust could help fuel future litigation. At the same time, MCOs will need to act fast to repair reputational damage by identifying opportunities to improve transparency and accountability.
In addition, payors face strengthened mental health parity rules, the risk of litigation over the use of artificial intelligence and new provider lawsuits stemming from the No Surprises Act.
Navigate this rapidly evolving, and complex landscape, by attending ACI’s 16th Annual Advanced Forum on Managed Care Disputes and Litigation, in Chicago, this spring.
Join in-house lawyers and outside counsel for timely analysis and takeaways from recent policy, regulatory and legal developments, so that you can manage disputes more effectively and protect your organization in these tenuous times.
On May 1–2, 2025, forge ahead with focused discussions, designed to help MCOs:
ĉ Leverage AI while mitigating litigation risks—specifically as it relates to use for prior authorization and coverage decisions
ĉ Improve fraud investigations and recovery efforts through effective communication and collaboration across the business and with outside counsel
ĉ Examine the growing role of private equity in healthcare and its impact on payor-provider relationships
ĉ Prepare for and contribute to an efficient arbitration process with favorable outcomes
EARN CLE CREDITS
Accreditation will be sought in those jurisdictions requested by the registrants which have continuing education requirements. This course is identified as nontransitional for the purposes of CLE accreditation.
ACI certifies this activity has been approved for CLE credit by the New York State Continuing Legal Education Board.
ACI certifies this activity has been approved for CLE credit by the State Bar of California.
ACI has a dedicated team which processes requests for state approval. Please note that event accreditation varies by state and ACI will make every effort to process your request.
For more information on ACI’s CLE process, visit: www.AmericanConference.com/Accreditation/CLE
AGENDA AT A GLANCE
CONFERENCE DAY 1
Thursday, May 1, 2025
8:00 am Networking Breakfast and Registration
9:00 am Opening Remarks from the Co-Chairs
9:10 am Managed Care State of the Union: The Politics and Policy of MCOs Under a New Administration
10:00 am Unpacking Loper Bright for the MCO Industry and Adjusting to a Post-Chevron World
10:45 am Extended Networking Break
11:15 am Ready or Not Here AI Comes: How Can MCOs Use Artificial Intelligence to Streamline Processes While Avoiding Regulatory Pitfall
12:00 pm Networking Luncheon
1:15 pm AI Usage on Care Determinations and Pending Lawsuits
2:15 pm Reading the Tea Leaves: What Are the Government’s Healthcare Enforcement Priorities?
3:00 pm Networking Break
3:15 pm Okay, Maybe a Few Surprises: An Analysis of Activity Surrounding the No Surprises Act After Texas Medical
4:00 pm ‘Ask an Arbitrator’ Returns: Reviewing Realtime Questions on Arbitration Dos, Don’ts and Best Practices
5:00 pm Day 1 Concludes to Networking Cocktail Reception
Sponsored by:
CONFERENCE DAY 2
Friday, May 2, 2025
8:00 am Networking Breakfast and Registration
9:00 am Opening Remarks from the Co-Chairs
9:05 am MCOs in the Public Eye: Improving Transparency and Public Perception
9:45 am Examining the Latest Rules, Challenges, and Confusion over Mental Health Parity
10:30 am Networking Break
10:45 am Fraud and Abuse Case Review: The Biggest Takeaways from a Year of Evolving Guidance and Enforcement
11:15 am Spotlight on MCO SIUs: How to Effectively Collaborate to Address Emerging Fraud and Abuse Concerns
12:00 pm Networking Luncheon
1:15 pm A New World of MCO Integration? Examining Potential Shifts in Antitrust Enforcement Priorities Under the New Administration
2:00 pm Star-Crossed: Examining the Latest Litigation Stemming from the Drop Star Ratings for Medicare Advantage Plans
2:45 pm Networking Break
3:00 pm 340B Drug Payment Remedy: Examining the Impact on Medicare Advantage Plan Rates and Contracts
3:45 pm Private Equity Healthcare Investment: Understanding Increased Oversight and the Impact on MCOs
4:30 pm Closing Remarks from the Co-Chairs and Conference Concludes
DAY ONE
Thursday, May 1, 2025
8:00 Registration and Networking Breakfast
9:00 Opening Remarks from the Co-Chairs
Korey Harvey Vice President & Deputy General Counsel Blue Cross and Blue Shield of Louisiana
9:10 Managed Care State of the Union: Politics and Policy of MCOs Under a New Administration
Assessing the first 100 days of the Trump administration, our panelists examine the actions taken thus far and what they expect to come down the pipeline in the next hundred days and beyond impacting managed care.
Some of the themes to be explored include:
• Examining what Trump 2.0 means for Medicare and Medicare program
• Anticipating the impact on the regulatory landscape
• Assessing what the agency nominations and appointments could portend for future action
10:00 Unpacking Loper Bright for the MCO Industry and Adjusting to a Post-Chevron World
In June 2024, the Supreme Court overturned 40 years of precedent through its decision in Loper Bright Enterprises v. Raimondo which overruled the doctrine of Chevon deference. Chevron had directed courts to defer to an agency’s reasonable interpretation of any ambiguity in a law under that agency’s jurisdiction. We are just beginning to feel the effects of this ruling and will likely be dealing with the fallout for years to come.
In this session, we will explore the immediate aftershocks and examine the road ahead, covering topics such as:
• Overview of the Supreme Court ruling in Loper Bright Enterprises v. Raimondo that upended 40 years of precedent and fundamentally changed our understanding of the Administrative Procedure Act
• Analyzing the immediate fallout of this decision and discussing what challenges have thus far been brought against previously established rules and regulations
• Investigating what the decision and its fallout could mean for guidance and rules issued to clarify and bolster the Inflation Reduction Act, Affordable Care Act, Antikickback Statute, Mental Health Parity and more
• Anticipating and preparing for ongoing and forthcoming disputes
• Exploring which jurisdictions are likely to be more or less friendly to existing statute and government interpretation
Baker Principal Groom Law Thomas Barker Partner Foley Hoag LLP
Xavier
11:15 Ready or Not Here AI Comes: How Can MCOs Use Artificial Intelligence to Streamline Processes While Avoiding Regulatory Pitfall
• Defining and distinguishing artificial intelligence from other advanced digital tools
• Assessing how AI is currently supporting the efficient management of complex tasks in health plan administration
• Deciphering the latest regulation, legislation, and guidance around the use of AI and emerging technologies in healthcare
• Understanding what we have learned over the past year and examining the pain points as MCOs implement artificial intelligence
» Examining how MCOs have gone about successfully employing technology in processes for MCOs without running afoul of the latest regulations
• Analyzing litigation and court rulings establishing precedent or scope of AI
» Assessing litigation risk based on what we’ve learned about AI usage
» Overseeing third party use of AI
12:00
1:15 AI Usage on Care Determinations and Pending Lawsuits
Join us for a conversation on the use of artificial intelligence in care determinations. During this panel, we will explore:
• Determining how big a role AI should play in the claim authorization process
• Examining pending litigation around the use of AI and algorithms in the prior authorizations
• Interpreting the latest guidance from CMS and other government agencies
Dorothy DeAngelis Senior Managing Director Ankura
Melissa Wong Partner Holland & Knight LLP
HANDSHAKE Global Sponsorship Opportunities
With conferences in the United States, Europe, Asia Pacific, and Latin America, the C5 Group of Companies: American Conference Institute, the Canadian Institute, and C5 Group, provides a diverse portfolio of conferences, events and roundtables devoted to providing business intelligence to senior decision makers responding to challenges around the world.
Don’t miss the opportunity to maximize participation or showcase your organizations services and talent. For more information, please contact:
Lanny Morris Senior Business Development Manager l.morris@americanconference.com
3:15 Okay, Maybe a Few Surprises: An Analysis of Activity Surrounding the No Surprises Act After Texas Medical
• Analyzing the latest decision by the 5th Circuit Court of Appeals upholding a district court ruling vacating QPA instructions
• Predicting the next cause of action in the protracted battle between payors and providers surrounding the NSA
• Exploring the latest developments in the IDR process
» When should providers bring actions to enforce the IDR award?
• Peeling back the veil on the arbitration process
» Breaking down the arguments most often made in these cases and revealing the most successful and unsuccessful tactics
» Dissecting the fallout from the Texas Medical decisions
» What guidance can be expected from the CMS following the Texas Medical decision being
Alex Lucas Partner Reed Smith LLP
Ray Walker
Managing Counsel, Litigation Blue Cross and Blue Shield of Illinois, Montana, New Mexico, Oklahoma & Texas
4:00 ‘Ask an Arbitrator’ Returns: Reviewing Realtime Questions on Arbitration Dos, Don’ts and Best Practices
In addition to its role in the IDR process under the No Surprises Act, arbitration plays a part in countless MCO disputes. Back by popular demand, this interactive panel, our experts will answer all the questions you’ve been afraid to ask! Topics will include:
• Understanding how the arbitration selection process works
• What is in-house counsel looking for? What is firm counsel looking for?
• What are the pros and cons to arbitrations with just one arbitrator versus an arbitration panel?
• Determining which disputes belong in arbitration and which belong in court
• Providing guidance around the true finality of an arbitration decision
Kirstin Ives Co-Founder Falkenberg Ives LLP
Christopher Keele Mediator and Arbitrator JAMS
Vice President American Arbitration Association International Centre for Dispute Resolution
5:00 Day 1 Concludes to Networking Cocktail Reception
Sponsored by:
The level of expertise of both the speakers and attendees results in meaningful discussions and practical advice.”
Diana Kruze Arbitrator, Mediator & Private Judge Judicate West
Moderator: Michelle Skipper National Healthcare
DAY TWO
Friday, May 2, 2025
8:00 Registration and Networking Breakfast
9:00 Opening Remarks from the Co-Chairs
Korey Harvey Vice President & Deputy General Counsel Blue Cross and Blue Shield of Louisiana
Alex Lucas Partner Reed Smith LLP
9:05 MCOs in the Public Eye: Improving Transparency and Public Perception
Renee Delphin-Rodriguez Chief Legal Officer & General Counsel SCAN
9:45 Examining
the Latest Rules, Challenges, and Confusion Over Mental Health Parity
In September 2024, the government issued “Final Rules under the MHPAEA,” strengthening federal laws on mental health parity requirements. As of January 1, plans cannot use NQTLs for mental health and substance use disorder benefits that are more restrictive than the predominant NQTLs as compared to medical and surgical benefits. In this session, we will dig deeper into the new rules and explore topics such as:
• Dissecting the new final rules from HHS, DOL, and Treasury and analyzing the early results from their implementation
• Interpreting how mental health, substance abuse, gender-affirming care, and other MHPAEA priorities are being evaluated
• Discussing the latest enforcement priorities under the new administration
• Understanding what the available guidance says and figuring out how to comply
• Providing updates from litigation in the 5th, 9th, and 10th Circuit courts
» Ryan S. v. UnitedHealth Group and E.W. v. Health Net Life Insurance Co.
» Examining Circuit courts findings on pleading standards in MHPAEA cases
• Assessing how mental health, substance abuse, gender-affirming care, and other MHPAEA priorities are being evaluated in view of recent cases
Joseph Laska Partner Manatt, Phelps & Phillips, LLP
Bradley Lerner Director, Public Policy, Manager, Behavioral and Enterprise Issues Elevance Health
Amanda Schreiber Senior Counsel, Legal & Corporate Affairs, Litigation Cigna Healthcare
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10:30 Networking Break
10:45 Fraud and Abuse Case Review: The Biggest Takeaways from a Year of Evolving Guidance and Enforcement
• Analyzing the latest litigation, particularly cases on the 2nd and 9th Circuits
• Examining the Justice Department’s action against Independent Health and DxID for fraud towards the Medicare Advantage program
• Deciphering the last year of shifting fraud and abuse enforcement priorities and regulatory guidance pertaining to MCOs
Michael Shaheen Partner
Crowell & Moring LLP
11:15
on MCO SIUs: How to Effectively Collaborate to Address Emerging Fraud and Abuse Concerns
• Exploring the role of internal Special Investigations Units (SIUs) in addressing fraud and abuse
» Examining how the volume of cases with law enforcement is leading to more active SIUs
• Identifying opportunities for the SIU to work with in house legal teams and outside counsel more effectively
» Detailing the impact of resourcing and different in-house structures on investigations
• Supporting defensive legal efforts with SIU leads
• Exploring perspectives on when to bring outside counsel into the investigation
» Assessing the value of having outside involved early to vet leads
• Determining whether to risk mitigate or pursue a lead
• Analyzing recent trends in fraud and billing schemes uncovered by SIUs
» How do SIU findings parallel government investigations into the healthcare industry?
• Examining litigation trends
» Plan sponsor plaintiffs
» Pushback on pre-payment review
12:00 Networking Luncheon
Daniel Lyons Managing Senior Counsel, Legal Department Aetna, a CVS Health Company
Nathaniel Moore Partner Robins Kaplan LLP
Kaelan Nagle Managing Director Ankura
Good event, moves at the right pace, good mix of plans and outside counsel.” This has historically been the best conference in Managed Care.”
1:15
A New World of MCO Integration? Examining Potential Shifts in Antitrust Enforcement Priorities Under the New Administration
• Evaluating the healthcare antitrust landscape
» How much direct competition is required to invite antitrust scrutiny from the authorities?
» What specific items are government agencies looking at when considering whether to further scrutinize a deal?
• Analyzing the premerger filing and clearance statutes in various states across the country
• Examining ongoing litigation as well as recent court decisions
» What can we glean from the ongoing Federal Trade Commission v. U.S. Anesthesia Partners case
» How closely are you going to be watching Oregon Association of Hospitals and Health Systems v. State of Oregon, a challenge to a new state law strictly regulating health care mergers
• Discussing the important of being extremely meticulous in all company communications when discussing any possible deal
• Dissecting new types of vertical integration and how they are being scrutinized (i.e. clearinghouses, pharmacy benefits, etc...)
Alexis Gilman Partner Crowell & Moring LLP
2:00 Star-Crossed: Examining the Latest Litigation Stemming from the Dip in Star Ratings for Medicare Advantage Plan
Over the last few years CMS has changed the methodology it uses to calculate MA plan star ratings. These changes have made it more difficult for plans to achieve ratings that will result in quality bonus payments. Plans have been steadily, and successfully launching lawsuits against CMS, in response.
Tyler Marshall Director BRG
• Analyzing the latest in litigation and fallout from Medicare Advantage star ratings system lawsuits
» Elevance Health v. Xavier Becerra resulted in a partial win for Elevance Health, ruling HHS violated the Administrative Procedure Act
» Centene, UnitedHealth, and Humana lawsuits against the HHS aiming to boost their star ratings
• Determining when to litigate over low star ratings
• Projecting potential reforms by CMS to address industry concerns over the current star ratings methodology
2:45 Networking Break
3:00 340B Drug Payment Remedy: Examining the Impact on Medicare Advantage Plan Rates and Contracts
• Examining the latest updates around the 340B Program and how they factor into government sponsored MCO plans
• Overview of CMS’ 340B remedy rule for payment cuts
• Examining how this will impact existing contracts between MA plans and 340b hospitals
• Anticipating future impacts on MA rates
• Analyzing how the latest HHS rules on the 340B Administration Dispute Resolution process are being put into practice
• Updating the latest litigation following AHA v. Becerra
» Following Eli Lilly and Company v. U.S. Department of Health and Human Services, challenging enforcement and regulatory actions requiring manufacturers to offer discounted prescription drugs to contract pharmacies
• Dissecting recent and ongoing disputes and preparing for the next round of litigation
Investment: Understanding Increased Oversight and
While private equity is not an entirely new entrant into the healthcare space, increased scrutiny and oversight across the managed care industry has led many to question how big a role PE should have in healthcare. This session will cover:
• Examining recent legislative, and regulatory developments impacting private equity in healthcare
» Understanding why Governor Newsom vetoed a bill that would have required PE funds and hedge funds to obtain consent before entering in healthcare transactions
» Examining proposed legislation in Pennsylvania that aims to impose notification requirements on healthcare facilities, systems or providers engaging in certain healthcare transactions
» Stalled legislation in Connecticut, Massachusetts, Minnesota, and Oregon
• Assessing whether scrutiny over private equity in healthcare will be as stringent under the Trump administration
» Anticipating potential shifts in FTC enforcement priorities and what this could mean for private equity firms exploring opportunities in healthcare
• Investigating how private equity firms are impacting providers and their relationships with MCOs
» Pinpointing where disputes could bubble up
