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Medicare, Medicaid & Commercial Coverage & Reimbursement

  • Represented Sanford Health, a non-profit integrated health delivery system, in its affiliation with The Evangelical Lutheran Good Samaritan Society (the “Society”), a non-profit long-term care provider. Our representation primarily focused on assisting Sanford in navigating the change of ownership filings for the Society’s licenses and Medicare and Medicaid filings. Sanford recently affiliated with and became the Corporate Member of The Evangelical Lutheran Good Samaritan Society (the “Society”), a non-profit long-term care provider with more than two hundred senior care locations in twenty-six states. Our representation primarily focused on assisting Sanford and the Society in navigating the change of ownership filings for the Society’s licenses and Medicare and Medicaid filings. As part of this work, we analyzed state regulatory requirements regarding changes of ownership and prepared and submitted the required change of ownership filings. Additionally, we provided counsel on the Society’s compliance program and post-closing enhancement recommendations.
  • For a health care provider, we performed a survey of approximately 18 states on Medicaid and Medicaid managed care eligibility, and specifically whether receipt of direct and/or indirect charitable assistance would impact the individual’s ongoing eligibility for Medicaid.
  • Advised a multi-state operator of skilled nursing facilities in several acquisitions, including health care regulatory compliance and Medicaid provider enrollment.
  • Under the Deficit Reduction Act (DRA), entities that do more than $5 million in Medicaid managed care business per year in any particular state, must have policies and offer training on federal as well as the respective state Medicaid fraud/abuse criminal and civil statutes, with focus on false claims provisions and whistleblower protections. For a PBM, we researched and wrote policies addressing those requirements for approximately 24 states, and updated them yearly as required by the DRA.
  • Representing UnitedHealthcare in negotiating the insourcing of its Medicare Part D PBM agreement to OptumRx (formerly Prescription Solutions).
  • Provided a reimbursement landscape assessment, specific to private insurance coverage policies, for a new medical device company. The assessment involved a coding analysis, a survey of coverage practices and categorization of such coverage policies into trends, and overall reimbursement landscape advice.
  • Provided HIPAA counsel to a retail pharmacy for a large, federal-state research collaboration involving Medicare pharmacy claims data. Advice included strategic planning to support multiple exchanges of massive amounts of Medicare claims data in an administratively simple way while complying with HIPAA privacy and security requirements.
  • Represented the purchaser of a home health agency with multiple office locations, including assistance with diligence questions, drafting asset purchase agreement, Medicare and Medicaid provider applications, state staffing agency licensure, and review of office leases, subleases and assignments.
  • Analyzed the impact of proposed Medicare National Coverage Decision on an integrated FDA and reimbursement strategy for a next generation sequencing cancer test and drafted comments to CMS.
  • Represented home care provider in internal investigation into Medicare/Medicaid and commercial payer billing practices.
  • Secured a dismissal of a False Claims Act suit brought by an ex-employee whistleblower who accused the company of knowingly overcharging Medicaid for the cost of pharmaceuticals.
Case Study
Mintz secured a full release of a biopharmaceutical company in a Louisiana state court case over alleged inflated drug price reporting. The client agreed to a nuisance value settlement of the case, resolving claims its actions cost the state’s Medicaid program more than $20 million.
Case Study
Mintz is helping a manufacturer and distributor of device systems used in wound treatment pursue Medicare and Medicaid coverage options throughout the country, including negotiating coding. Mintz attorneys met with the Centers for Medicare & Medicaid Services (CMS) regarding scope of coverage.