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Medicare/Medicaid Reimbursement
Our Health Care Practice offers counsel on a wide range of Medicare and Medicaid matters and, on behalf of providers, has successfully litigated (often obtaining settlements) against states and the U.S. Department of Health and Human Services in cases involving coverage or payment claims, limits and audits. We advise, negotiate and litigate in matters before administrative agencies and state and federal courts, and have a strong working relationship with the federal and state agencies responsible for overseeing the Medicare and Medicaid programs.
We represent hospitals and academic medical centers, including the New York City Health and Hospitals Corporation (“HHC”), which we have represented for almost 30 years; nursing homes; provider associations, including the Greater New York Hospital Association (“GNYHA”) and Healthcare Association of New York State (“HANYS”); physicians; rehabilitation agencies and CORFs; ambulatory surgical centers; home health agencies; hospices; dialysis companies; imaging centers; clinical laboratories; ambulance service providers; durable medical equipment suppliers; pharmacies; and third-party billing services in a wide range of Medicare and Medicaid reimbursement matters.
We also routinely counsel clients on federal and state fraud and abuse laws, including the anti-kickback laws, physician self-referral laws and the False Claims Act. We have conducted internal investigations of providers’ billing practices to determine compliance with applicable requirements, and have litigated and negotiated settlements of actions brought against providers under the False Claims Act.
Professionals
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Chicago
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Chicago
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New York
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New York
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Chicago
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New York
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New York
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Advice and Counsel: We routinely advise health care providers on a wide range of Medicare and Medicaid matters, including, for example, Medicare and Medicaid coverage
and billing requirements for inpatient and outpatient hospital services, clinic services, nursing facility services, ambulatory surgery services, and laboratory and radiology services, including bundling requirements, as well as compliance with fraud and abuse laws and regulations.
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Bellevue Hospital Center, et al. v. Leavitt. We represent 76 hospitals in a federal court action challenging the Secretary of HHS’s adoption
of revisions in the geographic area wage adjustments made to Medicare hospital payments. The new wage area boundaries reduce the plaintiff hospitals' Medicare reimbursement by $812 million.
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False Claims Act Cases/Investigations: We have represented health care providers in numerous federal False Claims Act investigations/cases involving allegations of duplicate Medicare billing,
improper billing of hospital transfers as discharges, laboratory "unbundling", and billing for medically unnecessary services. For example, we represent school districts in federal investigations of Medicaid billings for certain health services furnished to school districts to children in special education. We represented HHC in United States ex rel. McAllan v. City of New York, et al. , a qui tam action alleging that all Medicaid and Medicare claims for emergency ambulance services submitted for a period were false. The court granted our motion to dismiss the complaint on the ground that the allegations in the complaint had been publicly disclosed prior to the commencement of the action and were therefore subject to the statutory “public disclosure” jurisdictional bar.
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Issues Relating to "Disproportionate Share Hospitals" ("DSH"), "Upper Payment Limits," and "Intergovernmental Transfers": On behalf of GNYHA, we met with HHS to urge a change in federal policy that excluded certain categories of Medicaid
a change in federal policy that excluded certain categories of Medicaid patients from the statutory formula used to calculate Medicare DSH payments to hospitals that serve a disproportionate share of low income patients. HHS thereafter changed its policy to allow such Medicaid patients to be included in the DSH calculation. For many years, we also have offered advice and counsel on other complex issues involving hospital DSH payments, Medicaid "upper payment limits", and federal restrictions on the use of intergovernmental transfers ("IGTs") and hospital taxes/donations to fund State Medicaid programs.
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Medicare Coinsurance Limits: We
have been at the forefront in challenging State limits on Medicaid payments of Medicare coinsurance for dually eligible Medicare/Medicaid patients. We successfully challenged such payments limitations in numerous federal court actions in several states.
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Other Reimbursement Limitations: We have successfully challenged State utilization limits on covered Medicaid services; a State proposal to eliminate Medicaid payments for physician
services furnished in hospital emergency rooms; a State application of short-stay acute care admission and discharge criteria to specialty long term care hospitals; and other State audit disallowances of hospital cost reports. lawyers currently practicing in our Health Care Department have recovered, or averted the disallowance of, more than $1.5 billion in our clients' Medicare and Medicaid reimbursement.
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PRRB Appeals: We currently are prosecuting more than 150 group appeals before the CMS Provider Reimbursement Review Board.
These appeals seek to reverse certain audit disallowances imposed by the Medicare Intermediary that substantially reduced the providers' Medicare reimbursement by more than $200 million for the fiscal years at issue.
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