Client Services / Health / Reimbursement/Fraud & Abuse

Reimbursement/Fraud & Abuse

REIMBURSEMENT

Our Reimbursement practice encompasses all areas of government payor reimbursement including planning, judicial challenges to statutory and regulatory provisions of reimbursement programs and representation in Washington, D.C.  Our clients have operations throughout the United States and include medical centers, physician practice management companies, medical device manufacturers, trade associations, state hospital associations, trustees in bankruptcy, and holding companies that control health care providers.

Medicare & Medicaid Analysis & Advice
We have provided reimbursement advice to hospitals, nursing homes, physicians and suppliers on a range of issues such as investigational devices, bankruptcy matters, teaching physicians and reassignment.

Appeals
We have extensive experience in representing providers before the Provider Reimbursement Review Board, and physicians and suppliers in administrative law judge appeals.  These cases have involved a wide range of issues including TEFRA limits, resident training expenses, allowable charges and medical necessity.

Certification/Decertification
We have assisted clients in obtaining certification and fighting attempts at decertification, including representation of providers before administrative tribunals and in federal court.

Physician Self-Referral - Stark & State Law
The national scope of our health practice has resulted in our lawyers interpreting and applying the Stark Bill to a wide variety of transactions.  Seven of our lawyers collaborated on a book on this law titled Navigating Your Way Through the Federal Physician Self-Referral Law.  In addition we have advised clients on state self-referral laws.

Commercial Insurance/State Regulation
We have given reimbursement advice on issues related to commercial insurance, co-insurance waivers, secondary payor issues, and obtaining coverage for new drugs and devices.

Legislative & Regulatory Issues
On health care reform issues, we are provide extensive monitoring and lobbying services to a wide range of clients, including hospitals and networks specializing in women’s and infants’ peri-natal and high risk care; rural referral centers; ambulatory surgical centers; biomedical research facilities; radiation oncologists; manufacturers of medical imaging products; and drug and device manufacturing companies.


FRAUD & ABUSE

The Fraud & Abuse Counseling Practice within our Health Department covers virtually every facet of this issue. The national scope of our practice provides our lawyers with insights into the types of transactions likely to attract the attention of the Inspector General or prosecutors.  We assist clients in planning and structuring transactions to minimize fraud and abuse implications.  For transactions already formulated or implements, we provide advisory opinions on potential fraud and abuse concerns.

Our Firm’s extensive health law transactional work allows our lawyers to evaluate a wide variety of transactions under Medicare and Medicaid fraud and abuse statutes, safe harbor regulations, and the Stark legislation (which prohibits certain financial arrangements between physicians and entities which provide diagnostic and therapeutic services).  We analyze and advise clients on the implications of federal and state self-referral laws, which prohibit referrals by a physician to entities in which the physician has an ownership interest.

Through our Fraud & Abuse Practice Group, we also counsel to clients on hospital/physician joint ventures, including operation of MRI facilities, equipment lease arrangements, cancer treatment centers, home infusion therapy ventures, physician practice acquisitions and physician recruitment programs.  Numerous transactions relating to joint venture arrangements between hospitals and durable medical equipment suppliers have been evaluated by our health law practitioners. Finally, we provide advice to medical device manufacturers in connection with marketing programs aimed at hospitals, nursing homes, and physicians.

Complex fraud and abuse audits are another key element of our practice.  Through personal interviews and reviews and evaluations of all contracts and business relationships between a client and vendors or referral sources of referrals, potential fraud and abuse concerns are identified.  Similarly, we assist corporate clients in the development of compliance programs to prevent illegal activity by employees, and to minimize exposure to prosecutions and penalties.  These programs involve policy development, education of staff and early identification of such activity when it occurs.  Should a client become a target of an Inspector General investigation, we undertake protective reviews of client files to assess potential problem areas and develop an appropriate defense strategy.

Lawyers practicing in the criminal aspects of Medicare fraud and abuse investigations, including white collar criminal defense work, are also a part of our practice.  We have worked with clients who were the targets of grand jury investigations in an effort to persuade the prosecutor that it was not appropriate to treat the matter as a criminal activity.  In one such project, we developed an extensive position paper detailing confusion in the Medicare program with respect to billing issues.  We demonstrated that the correct billing requirements were far from clear, creating an element of reasonable doubt with respect to our client’s conduct.  We successfully persuaded the prosecutor to handle dispute as a civil matter.

Contacts

Health Client Services

McDermott Will & Emery

McDermott Will and Emery