Practices: Reimbursement

Medicare and Medicaid reimbursements account for nearly half of revenues for many healthcare providers, and contribute substantial revenue to physicians and suppliers. Accordingly, numerous rules and regulations address state and federally funded programs. In addition, third party payment from commercial sources is subject to an increasingly complex set of requirements. No matter what your role in the healthcare industry, you will benefit from legal counsel who understands the complex rules governing these programs. Effective reimbursement advice is also inseparable from ensuring full compliance with anti-kickback and other fraud and abuse regulations. Without complete guidance, you may be facing penalties – or even prosecution – for your reimbursement policies.

Full Spectrum

You can rely on Ungaretti & Harris for comprehensive counsel on the legal, compliance and policy issues governing the Medicare, Medicaid and other third party payor programs. Our reimbursement clients come from the full spectrum of healthcare provider and service organizations, including:

• General care and acute care/psychiatric hospitals, as well as academic medical centers.
• Nursing homes and long term care facilities.
• Home health agencies and hospice services.
• Physicians, physician organizations and clinics.
• Providers of diagnostic medical equipment, medical devices and pharmaceuticals.

No matter what your healthcare service or product, you get effective representation at all levels of the Department of Health and Human Services and its agencies, especially the Centers for Medicaid Services (CMS). An important part of that representation involves handling payment disputes before the CMS Provider Reimbursement Review Board (PRRB), the independent panel to which you can appeal if you are dissatisfied with a reimbursement decision. Our knowledge of the policies and personnel of these and other agencies gives you the insight necessary to effectively resolve reimbursement controversies and help you secure full payment.

Practical Assistance

Complying with the numerous government rules and regulations impacting health care provider reimbursement is highly complex and often confusing. You can face a reimbursement dispute, or even an allegation of non-compliance, by unwittingly running afoul of administrative requirements. You can avoid these problems with the practical claims, billing and reimbursement assistance that you get from our lawyers. That includes counsel on:

• Preparing and filing provider and supplier enrollment forms and designation applications.
• Responding to Peer Review Organizations, whether for inquiries regarding quality of care or denial of Medicare/Medicaid coverage.
• Qualifying for Medicare cost-limit exceptions and unique treatment designations.
• Handling all aspects of mergers, acquisitions and dispositions of health care operations as they relate to reimbursement, including recapture of Medicare losses.

Fraud and Abuse

Any healthcare provider could face allegations of fraud and abuse under federal and state laws regulating kickbacks, physician self-referral and insurance fraud, as well as Medicare and Medicaid billing and reimbursement rules. Increasingly, such allegations expose health care providers and provider organizations to the possibility of monetary penalties and even criminal prosecution. You need informed guidance on how to structure internal investigations and litigation defenses to meet the government’s tactics head on. Because members of our firm have been senior enforcement officials in both the United States Attorney’s and Illinois Attorney General’s offices, we know how to structure internal investigations and litigation defenses that meet the government’s tactics head-on. Our extensive relationships with former FBI, DEA and IRS agents enable us to put superb investigative resources at your service. If you face a False Claims Act investigation by the HHS Office of the Inspector General, you can confidently turn to us knowing that we have represented providers like you in investigations, administrative proceedings and trials.

Reimbursement Compliance

Beyond the fraud and abuse issue, reimbursement concerns often center on the everyday business activities of healthcare providers. Our work with such a wide range of provider organizations enables us to proactively identify reimbursement problems in your organization and work to reduce the risk. That means you can look to us to:

• Reduce or eliminate the risk of filing false claims, including DRG up-coding, billing for "unnecessary" services, incorrectly bundling and unbundling claims for services, billing for services using experimental medical devices, and other billing issues.
• Structure complex business arrangements and transactions, including acquisitions, joint ventures, and management agreements, to ensure compliance with all applicable reimbursement regulations.
• Perform “due diligence” reviews in connection with reimbursement issues.

Active Assistance

Rising healthcare costs have put more pressure than ever on the government programs created to make care and services available for those who need it most. In today’s highly politicized environment, that means Medicare and Medicaid reimbursement is one of the toughest operational concerns that any healthcare provider faces. Making the wrong decisions, or having incomplete information, risks anything from financial problems to criminal prosecution. That’s why you need the kind of active assistance that Ungaretti & Harris can provide. You’ll get the help you need to comply with the law, proactively address reimbursement issues, minimize problems, and maximize your defense in the event of disputes.