Reimbursement

As state and federal funds allocated to government health care programs become increasingly scarce, the regulatory schemes governing reimbursement become more and more complex. Mintz Levin has the knowledge and expertise to advise a wide range of clients on reimbursement in the public and private payor contexts.

We advise clients on the full spectrum of issues related to participation in government health care programs, including Medicare, Medicaid, TRICARE, the State Children’s Health Insurance Program, and the Federal Employees Health Benefits Program. For example, we counsel them on how to obtain Medicare coverage for new products, technologies, and services; the effect of operational and structural changes on reimbursement; and compliance with the requirements for participating in government health care programs.

Our attorneys also regularly represent clients in government investigations and litigation involving Medicare and Medicaid reimbursement issues. We have appeared before the Provider Reimbursement Review Board, the Departmental Appeals Board, and state and federal courts, and we have handled investigations conducted by the Office of Inspector General for the Department of Health and Human Services, the Department of Justice, Medicaid Fraud Control Units, and state attorneys general. Our recent accomplishments include:

• negotiating a $21 million settlement for a hospital client in a Medicare reimbursement appeal before the Provider Reimbursement Review Board
• serving as health care regulatory counsel to a hospital executive and his management company in a criminal cost report fraud case, United States v. Jones (5th Cir. January 16, 2007), and obtaining reversal of the district court’s sentencing and restitution order based on weaknesses in the government’s case
• advising clients on Medicare and Medicaid enrollment matters and preparing enrollment applications, including the CMS 855
• coordinating the Medicare and Medicaid change of ownership process for a variety of clients, including independent laboratories, hospitals, and home health agencies.

The health industry also faces a number of challenges related to private payor reimbursement. The pressure on providers and suppliers to participate in private payor networks is rising, new payment vehicles are appearing, and patients are becoming more savvy consumers who refuse to pay more to providers for their services. In light of these and other market forces, our health industry clients are facing various economic and operational dilemmas, and we can formulate practical, proactive strategies to address them.