Health Law

Medicare, Medicaid & Commercial Payor Coverage & Payment

The regulatory schemes governing health care reimbursement are increasingly complicated, making the threat of slashed payments a prevalent concern for your company. This is no small matter. Payments from governmental sources and commercial payors are the lifeblood of the US health care industry, and any reduction in reimbursements is a direct hit to the bottom line of providers, suppliers, manufacturers, and others across the health care continuum.

We can counsel your company on reimbursement in government as well as commercial payor contexts. Our Health Law attorneys routinely provide advice on the full spectrum of issues related to participation in government health care programs, including Medicare (Parts A, B, C, and D), Medicaid, TRICARE, the State Children’s Health Insurance Program, and the Federal Employees Health Benefits Program.

Doing business with commercial payors poses a separate set of challenges. The pressure on providers and suppliers to participate in commercial payor networks is rising, new payment vehicles are appearing, and patients are becoming more savvy consumers. Our lawyers have the experience to address your problems with practical, proactive strategies and tactics.

Representative Experience

  • Negotiated a $21 million settlement for a hospital client in a Medicare reimbursement appeal before the Provider Reimbursement Review Board.
  • Served 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. Jan.16, 2007), and obtained reversal of the district court’s sentencing and restitution order based on weaknesses in the government’s case.
  • Advise Medicare Part A providers and Medicare Part B suppliers on rules governing coverage and payment for the products and services they provide.
  • Counsel Medicare Advantage (MA) organizations and Medicare Part D plans on various program requirements, including bid development, plan design, marketing, enrollment, compliance, and fraud, waste, and abuse.
  • Assist MA organizations and Medicare Part D plans in preparing for and responding to audits by CMS and the Office of Inspector General for the Department of Health and Human Services.
  • Represent clients in government investigations and litigation involving Medicare and Medicaid reimbursement issues, including matters before the Provider Reimbursement Review Board, the Departmental Appeals Board, and state and federal courts.
  • Advise clients on Medicare and Medicaid enrollment and participation matters and prepare enrollment applications, including the CMS 855.
  • Coordinate the Medicare and Medicaid change of ownership process for a variety of clients, such as independent laboratories, hospitals, and home health agencies.
  • Counseled numerous independent laboratories on the rules governing billing and payment for services provided to hospital patients and prepared educational materials for internal and external use.