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Managed Care: Compliance and Enforcement

Managed Care: Compliance and Enforcement
Product Code - LGA189
Speaker(s): David M. Deaton, O'Melveny & Myers LLP; James G. Sheehan, New York City Human Resources Administration
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With increased government focus on health care fraud enforcement, managed care providers face an amplified risk of False Claims Act allegations. To protect themselves, managed care providers should take vigilant steps to ensure that they have comprehensive compliance programs in place.

The faculty for this program will address the expansion of False Claims Act cases and new theories being asserted by a growing number of plaintiffs and the qui tam bar, new compliance guidance, key considerations for developing or modifying a risk adjustment strategy that withstands government scrutiny, and how to develop effective compliance strategies and programs to incorporate these risks. The will also discuss recent enforcement actions, such as the WellCare trial in Florida and the Janke settlement and the outcomes of these actions, the expansion of risk adjustment, and the intersection of managed care with other considerations such as the Anti-Kickback Statute and medical loss ratios.

Educational Objectives:

• Understand the evolving compliance requirements in the Medicare Advantage program.
• Find out about the current enforcement landscape related to Medicare Advantage risk adjustment issues.
• Learn practical considerations for MA organizations in light of recent industry and enforcement trends.
• Discover the use of risk adjustment principles in other areas, such as Medicaid managed care programs and the Affordable Care Act’s insurance exchanges.

Who would most benefit from attending this program?

This program is intended for individuals in the office of the general counsel, compliance office, internal audit and special investigations units in health plans and contracted provider groups / provider management services organizations with responsibility for sales and outreach functions, managed care contracting, and financial functions.

It is also intended for outside counsel who represent these entities in the areas of regulatory compliance, white collar defense, contracting, transactional due diligence and other financial arrangements.

Program Level: Intermediate.

Credit Available: CLE. For more information, please click on the “CLE Credit” tab.

David M. Deaton, O'Melveny & Myers LLP; James G. Sheehan, New York City Human Resources Administration

David M. Deaton, O'Melveny & Myers LLP
David Deaton, a nationally recognized leader in health care law, is Co-Chair of O’Melveny & Myers LLP’s Health Care and Life Sciences Practice and a member of the White Collar Defense and Corporate Investigations Practice. Named one of the country’s “Outstanding Healthcare Fraud & Compliance Lawyers” by Nightingale’s Healthcare News, Mr. Deaton represents major health care organizations in complex, high-stakes regulatory, enforcement, and business matters. He conducts internal investigations for health care companies and audit committees, and he defends them in federal and state enforcement inquiries. He also counsels buyers and sellers in mergers and acquisitions, lenders and borrowers in loans and workouts, and health care companies facing strategic business challenges and opportunities.

In his thirteen years at O’Melveny, Mr. Deaton has assembled a record of expertise in the increasingly contested fields of state and federal anti-kickback and self-referral law (for example, the Stark laws), Medicare and Medicaid reimbursement law, state and federal privacy law, and managed-care regulation. He frequently writes and speaks on these issues for national audiences.

Mr. Deaton is admitted to practice in California. He earned a J.D. from Southern Methodist University, magna cum laude, where he served as Comments Editor of the SMU Law Review.

James G. Sheehan, New York City Human Resources Administration
Jim Sheehan is the Chief Integrity Officer for New York City’s Human Resources Administration, the nation’s largest social services agency, where he oversees integrity and compliance for 14,000 employees and more than 3.2 million social services recipients, including more than 2.5 million managed care enrollees. Mr. Sheehan was New York State’s first Medicaid Inspector General, with extensive involvement in compliance and oversight of managed care plans and investigation of fraud allegations involving providers, plans, and recipients. He was an Assistant U.S. Attorney for more than 20 years and a national leader in fraud and False Claims Act cases involving plans, PBMs, providers, and pharmaceutical companies.

Mr. Sheehan is a graduate of Harvard Law School and is certified in health care compliance by the Health Care Compliance Association. He is a member of the New York and Pennsylvania bars.

This program’s CLE-credit eligibility varies by state. Bloomberg BNA is an accredited provider in the states of New York*, California, Pennsylvania, Texas and Virginia, and most other jurisdictions grant CLE credit on a per-program basis. At this time, Bloomberg BNA does not apply directly to the states of Florida, Rhode Island, Montana and Hawaii although credit is usually available for attorneys who wish to apply individually. Additionally, the following states currently do not grant credit for Bloomberg BNA OnDemand programming: Arkansas, Ohio, Nebraska, and Delaware. All requests are subject to approval once the live webinar has taken place or the customer has viewed the OnDemand version. Please contact the Bloomberg BNA accreditations desk if you have specific questions that have not been addressed.

If you have further questions regarding a specific state or how to file for CLE credit, please contact Bloomberg BNA customer service at 800-372-1033 and ask to speak to the CLE Accreditation Coordinator.

Hardship Policy
Bloomberg BNA offers a hardship policy for attorneys earning less than $50,000 per year. If an attorney wishes to take advantage of this option, he or she must contact Bloomberg BNA directly. For attorneys who are unemployed or earning less than $35,000 per year, a full discount off the price of the program will be awarded upon written proof of hardship. Attorneys earning between $35,000 and $50,000 per year will receive a 50% discount off the price of the program. Any attorney working in the public service sector also qualifies for a special price. If you have further questions regarding the hardship policy or seek additional information, please contact Bloomberg BNA customer service at 800-372-1033 and ask to speak to the CLE Accreditations Coordinator, or email us at

For more information about Mandatory or Minimum Continuing Legal Education (MCLE) requirements, visit the American Bar Association website at

*Bloomberg BNA is an accredited provider in New York for experienced attorneys only.