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Health Care

Reimbursement Counseling/Fraud and Abuse Compliance

We advise clients on issues related to federal and state reimbursement systems, including coding and billing issues for physicians, physician groups, non-physician practitioners, and other health care providers, Medicare contracting, participation, coverage, reimbursement (including reassignment of the right to payment), and appeals, Medicaid contracting, coverage and reimbursement, rate setting, cost reporting and reconciliation, reimbursement of provider-based entities, and compliance issues (such as the identification and disclosure of overpayments, upcoding, unbundling, and other compliance problems, as well as medical records documentation practices and non-physician practitioner supervision requirements). We are experienced in representing clients before state Medicaid agencies, the Centers for Medicare and Medicaid Services, Medicare contractors, the Office of the Inspector General, and the United States Attorney’s Office.

Our experience helps us plan and structure transactions to minimize fraud and abuse implications, while at the same time achieving our health care clients’ desired business goals.  We regularly evaluate transactions and analyze their compliance with the Medicare and Medicaid fraud and abuse statutes, such as the Anti-Kickback Statute and safe harbor regulations, and the Stark Physician Self-Referral Laws and applicable exceptions.  Our experience in this area complements our role as transactional counsel to clients on hospital/physician joint ventures, including the operation of diagnostic imaging facilities, equipment lease arrangements, physician practice acquisitions, and physician recruitment programs.  We know the ins and outs of health care deals, and we steer our clients away from the pitfalls that trap the unwary.

We also assist clients with internal investigations and audits, as well as governmental investigations, audits, and settlements, and provide ongoing consultation regarding compliance with corporate integrity agreements (CIAs). Through on-site reviews and evaluations of contracts and business relationships between hospitals’ and physicians’ referral sources, we identify and analyze potential fraud and abuse concerns.  We then assist our clients in developing compliance programs and policies to educate staff (physician and non-physician), to prevent illegal activity by uninformed employees, to recognize and address compliance issues as they arise, and to minimize client exposure to prosecutions and penalties.