Medicare and Medicaid Payment and Certification
Ober|Kaler’s Health Law Group provides advice and assistance on Medicare and Medicaid payment, coverage and compliance issues to virtually all types of health care providers and professionals.
Collectively, our attorneys have an unsurpassed breadth and depth of experience in addressing these issues. Prior to joining Ober|Kaler, many of our attorneys worked in government service – both at the state and federal levels – and gained first-hand insight into how government regulators think and what their likely positions will be on particular issues. Other Ober|Kaler health care lawyers have spent time in hospital management and have a well-honed appreciation of the impact of the payment rules on the practical needs of patient care. In addition, we have attorneys who have spent years as federal or state prosecutors or as counsel to the Office of the Inspector General (OIG), giving them the ability to look at the payment rules from a prosecutor’s point of view.
As a result of these varied experiences, Ober|Kaler attorneys are able to quickly get to the heart of issues and analyze them with great efficiency. This results in our ability to deliver an “insider’s view” of Medicare and Medicaid rules to our clients in a cost-effective manner.
Advice on the Rules
Ober|Kaler attorneys have gained national recognition for their knowledge and experience in guiding health care providers through the maze of Medicare and Medicaid payment rules.
We understand the nuances – and the interplay – of the various prospective payment systems and fee schedules applicable to acute care hospitals, specialty hospitals, nursing facilities, home health agencies, physicians and non-physician practitioners. We also understand how they apply in non-hospital settings such as clinical laboratories, independent diagnostic testing facilities, ambulatory surgical centers and dialysis facilities. As a result, we are able to advise clients regarding the meaning and importance of particular payment policies, and how to comply with them from a billing and coding perspective.
Our attorneys also enjoy good working relationships with many officials in the Centers for Medicare & Medicaid Services (CMS). Where policies are unclear or questions arise, we have been very successful in obtaining clarifications required by our clients.
Our health law attorneys regularly assess compliance risks resulting from the application of Medicare and Medicaid payment rules. This includes conducting internal investigations when necessary, determining whether a situation raises any False Claims Act or fraud and abuse issues, and evaluating the necessity of returning overpayments.
Ober|Kaler has extensive experience in helping to shape government policy. We regularly review and advise our clients on proposed federal and state policies and regulatory changes, and assist in crafting our clients’ comments to these proposals. We have negotiated directly with CMS representatives on a wide range of Medicare issues. In addition, we assist clients in making their elected representatives aware of the impact their policy decisions will have on health care providers, and have drafted legislation to effect statutory changes in policy.
Medicare Payment Disputes and Appeals
Since 1971, Ober|Kaler attorneys have been representing clients in Medicare payment disputes. We regularly represent hospitals and other providers in individual and group appeals before the Provider Reimbursement Review Board.
We handle a wide range of issues, including:
- Wage index
- Direct and indirect medical education costs
- Disproportionate share hospital (DSH) adjustments
- Provider-based status
- Provider taxes
- Nursing and allied health
- Medicare bad debts
- Related party issues
- Specialized status qualification (e.g., sole community hospital or Medicare-dependent hospital status)
We also represent hospitals, clinical laboratories, physicians and other clients on Part A and Part B claims disputes before Medicare administrative contractors (MACs) and administrative law judges (ALJs).
During the course of administrative proceedings, we are often able to persuade the agency that the position it has taken is wrong. If those efforts do not succeed, we have the experience to challenge adverse agency rulings through judicial review in the federal courts or through direct challenges seeking injunctive relief. Our seasoned health law attorneys bring the strong litigation background needed to successfully pursue challenges in U.S. District Courts and U.S. Courts of Appeal. Two of our health care litigators have also presented Medicare cases before the U.S. Supreme Court.
Medicaid Disputes and Appeals
Our representation of health care clients in administrative disputes and litigation with state Medicaid agencies has involved numerous issues, including obtaining Medicaid payments for a variety of services and defending clients in connection with Medicaid Fraud Control Unit (MFCU) investigations, agency audits, overpayment demands and recoupment efforts.
We are experienced in dealing directly with government agencies as well as with their private contractors, including Medicaid Integrity Contractors (MICs). In addition, we have been extensively involved in Medicaid pharmacy and laboratory investigations, including cases involving Medicaid charge rules and “most favored nation” issues. Other cases handled by the Ober|Kaler health law attorneys include challenges to Medicaid reductions in coverage, under-reimbursement by Medicaid for hospital services, disputes involving outpatient psychiatric services and Medicaid waiver issues.
Our extensive experience and familiarity with state health departments and Medicaid agencies have also played a role in our ability to negotiate and successfully resolve conflicts for clients prior to the onset of any administrative or judicial proceedings.
Recovery Audit Contractor (RAC) Audits and Appeals
Ober|Kaler is experienced in defending all types of Medicare providers and suppliers against the denial of Part A and Part B claims resulting from local contractor probe audits or Program Safeguard Contractor (PSC) audits. We are one of very few law firms in the country with experience representing clients in RAC appeals in the program’s demonstration states.
We represent clients in all levels of the RAC appeal process. We also assist in-house counsel in these and other CMS-related issues, thus allowing our clients even greater cost efficiencies. As CMS rolls out the permanent RAC program, we are helping clients prepare for RAC audits in a practical and economical manner.