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Medicare/Medicaid Reimbursement

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Overview

Our Clients

We represent health care providers and other entities in a wide range of Medicare, Medicaid and commercial reimbursement matters. Our clients include hospitals and academic medical centers, long-term acute care hospitals, ambulatory surgical centers, diagnostic and treatment centers, nursing homes and hospices, provider associations, physicians and physician groups, rehabilitation agencies, comprehensive outpatient rehabilitation facilities, home health agencies, dialysis companies, imaging centers, clinical laboratories and durable medical equipment suppliers, pharmacies, hospital management companies, emergency ambulance services, third-party billing services, 340B entities, and federally qualified health centers (FQHCs).

Our Services

Katten's Health Care team advises on, negotiates and litigates reimbursement and related matters before administrative agencies including the Provider Reimbursement Review Board (PRRB), as well as state and federal courts. As a result of our strong working relationships with the federal and state agencies responsible for overseeing the Medicare and Medicaid programs, we can often obtain clarification on reimbursement issues that may not be clear on the face of published regulations and guidance.

Clients engage us to conduct internal investigations of provider billing practices to determine compliance with applicable requirements. We represent providers in government audits and have litigated and negotiated settlements of actions brought against providers under both federal and state False Claims Acts involving allegations of duplicate billing, billing for medically unnecessary services, billing for services by unlicensed providers, and violations of the Stark Act and anti-kickback statute. Other False Claims Act cases involve allegations that providers billed for physician services in teaching hospitals, school-based health care services, early intervention services and personal care services in violation of applicable requirements.

By closely monitoring the various legal reforms and reimbursement changes that are driving clinical integration initiatives across the country, we are able to provide clients with informed counsel on innovative reimbursement methodologies including bundled payment programs, accountable care organizations (ACOs) and other health care initiatives.

In addition, we regularly assist clients with facility licensing and Form 855 preparation. Our attorneys help new providers enroll in the Medicare and Medicaid programs and existing providers complete change of information filings in accordance with Centers for Medicare & Medicaid Services (CMS) requirements. We also work with health system, private equity and national ancillary care providers to address facility licensing and Medicare/Medicaid enrollment issues in connection with mergers, acquisitions, joint ventures and other change of ownership situations.

Experience
  • Defense of a large health care provider in a False Claims Act litigation in which the Government alleges submission of false claims to the Medicaid program for early intervention services to developmentally delayed children.
  • Defense of a 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.
  • Provision of advice to a large health care system in connection with 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.
  • Representation of a large health care system in the prosecution and settlement of hundreds of Medicare appeals before the Provider Reimbursement Review Board.
  • Representation of a large health care system in opposing numerous government audits and investigations, including negotiating settlements of threatened recoupment of Medicare and Medicaid payments. 
  • Counsel to a 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. Katten successfully negotiated a settlement of less than one percent of the initial audit finding.
  • Counsel to a 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.
  • Provision of assistance to a large health care system in participating in New York State’s federally approved DSRIP program; Katten is advising on federal demonstration program requirements and regulatory compliance matters.
  • Representation of a large health care system and physician group as defendants in a 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. 
  • Representation of a public hospital in a trial against the New York State Office of the Medicaid Inspector General involving novel issues of what services provided to undocumented aliens are reimbursable under Medicaid.
  • Provision of services to a hospital trade association and its members, including 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.
  • Representation of a 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.
  • Provision of assistance to a hospital system in converting its freestanding clinics to FQHCs.
  • Provision of advice to a large hospital system in connection with purchasing of drugs under the 340B discount program, and related 340B compliance issues.
  • Representation of a managed care organization in seeking recovery of overpayments made to a health care provider.
  • Provision of advice to an organization concerning the application of the corporate practice of medicine doctrine, fee-splitting prohibitions, scope of practice restrictions and health facility co-location issues. 
  • Primary outside counsel to a large health care system in a variety of matters, including defense in suspected Medicare/Medicaid fraud and False Claims Act investigations, assistance regarding supplemental Medicaid payments, opposing government audits, creation and implementation of a corporate-wide compliance program, effecting a major reorganization of physician staffing relationships, prosecution of Medicare appeals, 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 a large municipal school district in obtaining dismissal of a 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.
  • Representation of a large municipal health system in a suit filed against the federal Medicare agency alleging an illegal and arbitrary cap on reimbursement cost apportionment.
  • Provision of advice to a hospital management firm in settlement of allegations that it breached the False Claims Act by aiding the inappropriate admissions of patients for hospital services. Katten's client did not admit any wrongdoing and is one of several defendants in New York federal litigation dating back to 2002.
Events
April 30–May 1, 2015
March 1–3, 2015
Medicare/Medicaid Reimbursement

Recognition

U.S. News Best Lawyers "Best Law Firms" – Health Care Law (New York)
Health Care Law (New York), 2011–2019
Chambers USA – Healthcare (Texas)
Healthcare (Texas), 2006–2019
U.S. News Best Lawyers "Best Law Firms" – Health Care Law (Chicago)
Health Care Law (Chicago), 2011–2019
Chambers USA – Healthcare (New York)
Healthcare (New York), 2006–2019
Legal 500 US – Healthcare: Service Providers
Healthcare: Service Providers, 2016–2019
U.S. News Best Lawyers "Best Law Firms" – Health Care Law (National)
Health Care Law (National), 2013–2019
Chambers USA – Healthcare (Illinois)
Healthcare (Illinois), 2006–2019
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Recognition

Health Care Law (New York), 2011–2019
Healthcare (Texas), 2006–2019
Health Care Law (Chicago), 2011–2019
Healthcare (New York), 2006–2019
Healthcare: Service Providers, 2016–2019
Health Care Law (National), 2013–2019
Healthcare (Illinois), 2006–2019

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Health Care Perspectives - A Health Care Industry Knowledge Resource

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