Professional Experience
Mr. Oakley is one of the leading health care reimbursement lawyers in New York. Over the past 30 years he has been involved in nearly every aspect of health care payments in New York, particularly at the legislative and regulatory levels. He is best known for his work on the technical details of DRG inpatient hospital systems, outpatient rates, incorporation of quality measures into payment rates, creation of community reimbursement systems such as global budgets, and regional input into health care system structures. Mr. Oakley works extensively on related aspects of payment rates, including associated issues of claims payments and coding to obtain the appropriate rate. He represents numerous large hospitals, but also represents specialty hospitals and one of the smallest hospitals in the State. His expertise includes contracts between hospitals and payors where he advises clients regarding rates and assumption of financial risk. Given his prior experience with community-wide payment systems and payment rates, he was the lead attorney for all legal, regulatory and contracting issues to establish one of the largest Medicare Pioneer Accountable Care Organizations.
Mr. Oakley was involved in helping create the New York's Health Care Reform Act (HCRA) system of negotiated hospital rates by private payors which includes State mandated surcharges on hospital claims, assessments on the number of covered lives, and special payments for graduate medical education. He represents many hospitals and payors in State audits of their HCRA obligations. His unique expertise in rate issues has led to frequent involvement in litigation, such as the U.S. Supreme Court's groundbreaking decision in the Travelers case upholding state rate surcharges from ERISA preemption.
Mr. Oakley previously represented many of the largest health plans in their New York operations, especially with regard to HMO licensure, premium rates and underwriting, and all aspects of managed care. His extensive knowledge of the payor world provides insights that most other health care attorneys do not have. Mr. Oakley was extensively involved in New York's creation of mandated community rating and an open enrollment system, as well as the associated risk adjustment process among health plans. For many years he has been extensively involved in the details of premium rate regulation, with a particular focus on assisting insurers to explain and justify their proposed premium increases, as well as navigating the regulatory and political process surrounding premium increases. That work has included many successful challenges to regulatory overreaching, such as court rulings against the New York State Insurance Department's efforts to limit insurers' rights to establish premium rates.
Memberships & Activities
Admitted to practice in New York.
Member, New York State Health Department HCRA advisory committee.
Member, New York State Insurance Department payor-provider roundtable.
Publications
"HMO Liability for Malpractice of Member Physicians: The Case of IPA Model HMOs," Torts and Insurance Law Journal, Spring 1988.
Speaking Engagements
Greater New York Hospital Association.
Blue Plan (BCBS) Legal Department Cooperative-National Teleconference Series.
American Health Lawyers Association.
American Bar Association Torts and Insurance Practice Section.