Medicare/Medicaid Reimbursement

Experience

• Defended large health care provider in False Claims Act litigation. Government alleged submission of false claims to the Medicaid program for early intervention services to developmentally delayed children. Court granted in part our motion to dismiss.
• Defended major US municipality and public hospital system in a federal False Claims Act qui tam litigation brought by a whistleblower, alleging the submission of false Medicaid claims for hospital, long-term care and other services.
• Advise large health care system on complex federal and state regulations governing supplemental Medicaid payments, such as Disproportionate Share Hospital, Upper Payment Limit payments and value-based payments under a federal waiver program.
• Represent large health care system in prosecution and settlement of hundreds of Medicare appeals before the Provider Reimbursement Review Board.
• Represent large health care system in opposing numerous government audits and investigations, including negotiating settlements of threatened recoupment of Medicare and Medicaid payments. 
• Counseled major health care system’s long-term home health care program in challenging a threatened recoupment by the New York State Office of the Medicaid Inspector General of millions of dollars' worth of Medicaid payments. We negotiated a settlement of less than one percent of the initial audit finding.
• Counsel large health care system in establishing and operating an Accountable Care Organization, including assistance in applying for participation in the Medicare Shared Savings Program and applying for designation by the New York State Department of Health as an Accountable Care Organization.
• Assist large health care system in participating in New York State’s federally approved DSRIP program. We are advising on federal demonstration program requirements and regulatory compliance matters.
• Represent large health care system and physician group as defendants in qui tam False Claims Act case before the US District Court for the Eastern District of New York alleging submission of false Medicare and Medicaid claims for podiatry services and for medical education reimbursement. 
• Represent public hospital in trial against the New York State Office of the Medicaid Inspector General. Involves novel issues of what services provided to undocumented aliens are reimbursable under Medicaid.
• Assist hospital trade association and its members. Services include preparing legal challenges to State Medicaid budget cuts; assisting in developing programs to expand health insurance coverage; and advising on matters involving Medicare and Medicaid reimbursement, fraud and abuse, intergovernmental transfers, Medicaid State Plan Amendments, provider taxes and payment limitations, and Medicare graduate medical education payments.
• Represent hospital in a civil investigation being conducted by the US Attorney’s Office for the Eastern District of New York involving novel issues of Medicaid coverage of services furnished to certain categories of patients.
• Assist hospital system in converting its freestanding clinics to FQHCs.
• Advise large hospital system in purchasing drugs under 340B discount program, and related 340B compliance issues.
• Represent managed care organization in seeking recovery of overpayments made to health care provider.
• Advise organization concerning application of corporate practice of medicine doctrine, fee-splitting prohibitions, scope of practice restrictions and health facility co-location issues.
• Primary outside counsel to large health care system in various matters. We defend client in suspected Medicare/Medicaid fraud and False Claims Act investigations, assist regarding supplemental Medicaid payments, oppose government audits, and created and implemented a corporate-wide compliance program. We also helped effect a major reorganization of affiliate relationships; prosecute Medicare appeals; and counsel on HIPAA and health care privacy matters, provision of health services in correctional facilities, and a threatened suit against the State regarding Medicaid payments.
• Counsel to large municipal school district in obtaining dismissal of qui tam case alleging violations of the False Claims Act in connection with the school district's Medicaid claims for case management services. The case is on appeal before the US Court of Appeals for the Second Circuit.
• Represent large municipal health system in a suit filed against the federal Medicare agency alleging an illegal and arbitrary cap on reimbursement cost apportionment.
• Advised hospital management firm in settling allegations that it breached the False Claims Act by aiding the inappropriate admissions of patients for hospital services. Our client did not admit any wrongdoing and is one of several defendants in New York federal litigation dating back to 2002.