Attorneys in the Healthcare Department’s reimbursement practice have handled a myriad of reimbursement matters and claims denial cases for hospitals and health systems, physicians and physician group practices, ambulatory surgery centers, nursing homes and other healthcare providers. We have extensive experience challenging all types of federal and state reimbursement issues, including those pertaining to Medicare and Medicaid cost reporting and federal disproportionate share hospital reimbursement, as well as state subsidy fund payments, such as payments for charity care, graduate medical education, hospital relief, and mental health.
Our attorneys regularly represent hospitals and other providers, both individually and in group appeals, challenging reimbursement issues before the Provider Reimbursement Review Board (PRRB), state administrative agencies, and in federal and state courts, including defending our healthcare clients in Federal False Claims Act and state insurance fraud cases, as well as investigations by the Medicaid Fraud Division.
Representative Matters
Lawyers in our reimbursement practice have had leading roles in the following Medicare/Medicaid/disproportionate share hospital reimbursement matters:
- Successful settlement of federal District Court action challenging the U.S. Department of Health and Human Services’ denial of Medicare reimbursement due hospitals as a result of a loss on the sale of the hospitals’ depreciable assets (recapture).
- Representation of hospitals and academic medical centers in administrative appeals before the PRRB challenging their final Medicare Cost Report Settlements spanning a number of fiscal years.
- Group appeal representation of 33 hospitals challenging the adequacy of their Medicaid rates under the regulatory marginal loss formula and the failure of the State Medicaid program to apply the correct TEFRA economic factor to the hospitals’ Medicaid DRG rates.
- Representation of multiple hospitals challenging their state fiscal year charity care, HRSF, and GME subsidy allocations in administrative appeals before the New Jersey Department of Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services (DMAHS).
- Representation of 25 hospitals in federal court challenging on Equal Protection grounds CMS' refusal to permit them to include charity care inpatients days in the Medicaid proxy of the Medicare DSH calculation, when CMS permits hospitals in other states that have been granted an 1115 waiver to include substantially similar days in their Medicare DSH calculation.
- Representation of 14 New Jersey hospitals challenging the requirement that the hospitals provide treatment to all patients without regard to the patients' ability to pay or source of payment as an as-applied violation of the Takings Clauses of the United States and New Jersey Constitutions.
- Representation of inner-city safety net hospital alleging that DMAHS failed to properly count certain patient admissions for purposes of qualifying hospital for $6 Million in HRSF subsidy funds.
- Representation of 20 hospitals in administrative hearings on final settlements before DMAHS challenging the Medicaid program’s refusal to “add back” physician time on Worksheet D-3 of the hospitals’ Medicaid cost reports.
Our attorneys have prosecuted significant Medicare and Medicaid appeals from the administrative level through the federal appellate courts. Our experience includes issues involving:
- Rural floor budget neutrality adjustments to Inpatient Prospective Payment System (IPPS) rates
- Outlier payments
- Wage index issues
- IME/GME resident counts
- Medicare DSH appeals involving:
- Medicaid eligible days
- Inclusion of SSI days in the Medicare proxy
- Inclusion of Medicare Advantage (Part C) days in the Medicaid proxy
- Inclusion of general assistance days in the Medicaid proxy
- Charity care/Medicaid DSH days
- Section 1115 waiver days
- TEFRA adjustments