Noreen Vergara

Insurance and Managed Care

• Advises insurers and health maintenance organizations (HMOs) on entering into new managed care markets including Medicare Advantage, Medicaid, health insurance exchange plans and commercial products.
• Advises managed care organizations and provider risk-bearing organizations on matters involving utilization review, claims processing and vendor management.
• Led due diligence in a $80M managed care acquisition and oversaw subsequent integration activities including the re-contracting of over 8000 health providers across the country.
• Advised various state departments of insurance on Affordable Care Act health insurance exchange development
• Represented Mississippi Farm Bureau Federation in establishing state nonprofit agricultural membership organization (NAMO).

Healthcare Reimbursement

• Represents various managed care entities and providers who engage in value-based contracting, capitation and other risk-based payment options in complying with federal and state regulations.
• Developed and implemented clinical joint ventures among insurers and other payors, hospital systems, freestanding emergency centers, community mental health centers, physician practices, substance use disorder treatment facilities and peer support organizations.
• Develop and implement reimbursement arrangements for providers involved in accountable care organizations (ACOs), shared-savings payment structures, care coordination programs and social determinants of health programs.
• Advise behavioral health treatment providers, medication assisted treatment (MAT) programs, psychedelics assisted therapy providers and peer support organizations on regulatory and compliance issues including telehealth requirements, corporate practice, fee splitting and referrals, and privacy and security.

Provider and Payor Alignment and Integration

• Advises provider networks and management services organizations on developing contracting plans involving thousands of practitioners of varying licensures.
• Successfully resolved a multi-contract claims payment dispute between a large multispecialty provider group and a national payor system resulting in a $4 million underpayment recovery for the client.
• Advises behavioral health providers and facilities on the development of new facilities and programs financed through multiple channels including private equity investment, federal and state grants, and Medicaid expansion funding.

Privacy and Data Security

• Advises clients on responding to health information privacy security incidents involving millions of patients' electronic medical records across multiple states. Advises clients on appropriate responses and best practices to protect patient data.
• Advises clients on developing compliant solutions to secure and appropriately share behavioral health treatment information.
• Served as HIPAA Privacy Officer at national managed behavioral health venture for millions of health plan members requiring ongoing development and delivery of compliance training, including federal and state requirements for mental health and substance use medical records.

Compliance Counseling

• Advises behavioral health providers and facilities, telehealth organizations, and physician practices on general corporate, employment and regulatory matters.
• Advises insurers and other payors on compliance with commercial, Medicare Advantage and Medicaid managed care regulations.
• Counsels clients through reimbursement and overpayment audits and assists clients with claims reimbursement issues.
• Created and operated multistate managed care organization's mental health parity compliance program.
• Advised on issues including Affordable Care Act (ACA) implementation, Medicare Supplement requirements, coordination of benefit requirements, third-party administrator guidelines, medical-loss ratio requirements, limited medical benefit plans and health insurance exchange development.

Behavioral Health

• Advises behavioral health providers on implementation and governance of artificial intelligence technologies, including privacy, transparency, consent, and regulatory compliance considerations.
• Counsels community mental health centers and substance use disorder treatment providers on HIPAA and 42 CFR Part 2 compliance, patient information sharing, intake processes, telehealth, and workforce training.

AI and Health Technology

• Structures healthcare technology and data sharing arrangements involving protected health information, business associate relationships, information security obligations, and healthcare innovation initiatives.

Provider Reimbursement and Payor Strategy

• Represents providers in reimbursement disputes involving commercial insurers, including underpayment matters, network adequacy issues, and single case agreement reimbursement disputes.
• Advises clinically integrated networks and provider organizations on governance, performance incentives, quality improvement initiatives, and value-based reimbursement arrangements.