King & Spalding attorneys and consultants have decades of experience in understanding the intricacies of the healthcare industry and obtaining coverage, coding and appropriate reimbursement for our provider and pharmaceutical/biotech and medical device manufacturer clients. We pride ourselves in our in depth knowledge of the reimbursement problems faced by our clients and developing cutting edge strategies to solve these problems.
Medicare/Medicaid Payment and Regulatory Counseling
When a healthcare business participates in the federal Medicare or the federal/state Medicaid program, the applicable regulatory burdens increase, and the risks from a business perspective become substantial. Our attorneys have years of experience in understanding the intricacies of the healthcare industry and of federal and state programs for financing payment for products and services. For both Medicare Part A and Part B, we have profound knowledge of the reimbursement systems applicable to suppliers, practitioners and providers. We counsel clients on issues relating to cost-based, charge-based and prospective payment reimbursement systems. 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. 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.
Reimbursement, Coverage and Coding Counseling
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. We have worked with providers and suppliers to maintain the most updated information on changes in coverage, documentation and record-keeping requirements.
Medicare/Medicaid Reimbursement Litigation
Our experience with reimbursement litigation is deep and wide. We have handled every type of Medicare appeal, 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; provider-status disputes that proceed to the Departmental Appeals Board; and civil money penalty disputes heard by Administrative Law Judges. 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 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 a billion dollars in payments to our clients.