Healthcare Reimbursement

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Medicare/Medicaid Payment and Regulatory Counseling

Our attorneys have years of experience in understanding the intricacies of the Medicare and Medicaid programs.  For both Medicare Part A and Part B, we have profound knowledge of the reimbursement systems applicable to providers, suppliers and practitioners.  We counsel clients on issues relating to cost-based, charge-based and prospective payment reimbursement systems, as well as Medicare and Medicaid disproportionate share hospital payments, graduate medical education reimbursement, and Medicare and Medicaid electronic health records incentive payments.  At a time when budgetary considerations are squeezing governmental health programs, a keen understanding of these payment systems is essential to providers’ fiscal stability. 

Indeed getting started as a Medicare or Medicaid provider requires familiarity with a broad range of regulatory issues related to enrollment and certification.  Maintaining provider status is no different.  We provide advice to healthcare providers, practitioners and suppliers in all aspects of establishing and maintaining their participation status in the Medicare and Medicaid programs.  We keep our clients abreast of changes in federal laws and regulations.  The Firm and its attorneys have worked with CMS, HHS and OIG for many years in a variety of settings and contexts.  We understand the important and persuasive policy considerations that drive decision making in those agencies and can use those insights to serve as effective advocates for our clients. 

In addition, we work with providers and suppliers to maintain the most updated information on changes in coverage, documentation and record-keeping requirements.  We also obtain appropriate coverage, coding and reimbursement determinations for our pharmaceutical/biotech and medical device manufacturer clients. Our attorneys are able to advise providers and suppliers on coverage, working on the client’s behalf with CMS and its contractors to obtain coverage for new technologies, to resolve new issues and settle disputes. 

Medicare/Medicaid Reimbursement Litigation

Our experience with reimbursement litigation is deep and wide.  We have handled every type of Medicare appeal there is, including cost report payment disputes heard by the Provider Reimbursement Review Board (PRRB); coverage disputes that proceed from the redetermination process through an Administrative Law Judge to the Medicare Appeals Board; and provider-status disputes that proceed to the Departmental Appeals Board.  

We also represent clients before Administrative Law Judges in claims denials, civil monetary penalties and enrollment disputes.  We assist providers and suppliers in challenging denials and overpayments determined on pre- and post-payment reviews by Medicare Administrative Contractors, by RAC and ZPIC auditors, and by enforcement authorities.  We challenge suspension of payments, recoupment actions, develop extended repayment plans and challenge findings based on sampling methodologies and extrapolation.  Successful appeals that our lawyers have handled have resulted in well over $1 billion in payments to our clients.

Our reimbursement lawyers include the former head of all Medicare reimbursement litigation at the HHS Office of General Counsel.  Our lawyers have simultaneously represented thousands of hospitals in hundreds of appeals to the PRRB and in federal court, although many of our cases are resolved prior to having a hearing being conducted by the PRRB.  Among the successful outcomes are winning the rural floor budget neutrality case in the D.C. Circuit Court of Appeals in the case of Cape Cod Hospital v. Sebelius.  This opinion was the basis for a favorable settlement for thousands of hospitals resulting in payments exceeding $3 billion.  We also obtained several favorable PRRB decisions on whether medical residency programs are considered “new” programs for purposes of Medicare GME payment, cases worth in excess of $20 million to some providers.

Mark D. Polston 
T: +1 202 626 5540 WASHINGTON, D.C.