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The healthcare reimbursement system is extremely complex, with the rules governing healthcare reimbursement changing often. This complexity can make it challenging for health providers, as well as pharmaceutical, biotechnology and medical device manufacturers, to understand the rules and processes and keep up with the changes. Our job is to help make your job easier.

Compliance and Reimbursement Programs that Work

Our attorneys and government relations professionals fully understand the complexities of obtaining coverage, the necessity for proper coding and the requirements for obtaining appropriate reimbursement and can assist you with developing solutions to reimbursement issues. In fact, our team includes reimbursement attorneys who formerly represented Medicaid programs in New Jersey and Pennsylvania. Our healthcare attorneys often work closely with our federal government relations practice and our FDA practice.

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Navigating the Reimbursement Maze

Our experienced healthcare attorneys have developed longstanding relationships with governmental payors to help you with all of your reimbursement issues. To provide you with current and appropriate information and counsel, we stay in close contact with:

  • Policymakers.
  • Federal agencies.
  • Centers for Medicare and Medicaid Services (CMS).
  • State Medicaid and Medicare offices.
  • American Medical Association.
  • Other governmental or quasi-governmental agencies.

Additionally, our healthcare lawyers have experience negotiating and helping to resolve disputes with commercial payors. Whether negotiating a managed care agreement, a pay-for-performance agreement, or patient home agreement, we have you covered. 

In addition to handling routine health provider reimbursement issues, whether with governmental or commercial payors, we can help you with:

  • Reimbursement matters related to new technology.
  • Upper payment limit and disproportionate share programs for academic medical centers and faculty practice plans to maximize Medicaid reimbursement.
  • Understanding the rules related to resident and intern supervision and reimbursement for graduate medical education.
  • Reimbursement matters related to organ transplant program.
  • Issues such as provider-based status, incident to billing, related parties, purchased diagnostic tests, telemedicine and global surgery billing.
  • Written compliance plans with hospital policies and procedures that reflect federal and state statutes and regulations regarding direct and indirect graduate education reimbursement.
  • ACOs and new payment programs.
  • Negotiation of provider agreements.
  • In and out-of-network reimbursement issues.

Healthcare Fraud and Abuse

Healthcare providers are under increased pressure to guard against allegations of Medicare and Medicaid fraud and abuse. Whether related to federal/state false claims, Stark and Anti-Kickback laws, or many other statutes and regulations, we can help with: 

  • Conducting or assisting with internal investigations.
  • Managing internal investigations stemming from allegations of documentation or billing irregularities, unethical conduct or violations of law or regulations.
  • Responding to government inquiries and documentation requests such as subpoenas.
  • Helping with grand jury, OIG and Medicaid investigations.
  • Resolving litigation, negotiation and settlement of government claims.
  • Preparing advisory opinion requests for submission to the OIG.
  • Counseling regarding whistleblower and related concerns.
  • Advising regarding conflicts of interest and other corporate matters.
  • Responding to complaints and investigations regarding EMTALA.