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Hospital & Physician Reimbursement

Attorneys in the healthcare group’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 (DSH) reimbursement, as well as state subsidy fund payments, such as payments for charity care, graduate medical education, hospital relief, and mental health. We regularly represent hospitals and other providers, both individually and in group appeals, challenging reimbursement disputes with Medicare Advantage, Medicaid managed care, and commercial insurance plans, as well as appeals before the Provider Reimbursement Review Board (PRRB), state administrative agencies, and in federal and state courts.

Our reimbursement team has prosecuted significant Medicare and Medicaid appeals from the administrative level through the highest level of 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, and IME/GME resident counts. We have handled Medicare DSH appeals involving Medicaid eligible days, as well as the inclusion of SSI days, Medicare Advantage (Part C) days, and general assistance days in the Medicaid proxy. Our experience also encompasses charity care/Medicaid DSH days, Section 1115 waiver days, and TEFRA adjustments.

In addition, we have regularly challenged decisions by Medicare, Medicaid, or managed care organizations within the context of overpayment appeals, medical necessity denials, coding and billing disputes, and enrollment and credentialing denials.

Representative Matters

  • Representing two New Jersey health systems in high-stakes litigation against multiple Medicare Advantage plans seeking recovery of approximately $5 million in underpaid 340B drug reimbursements, following a U.S. Supreme Court decision invalidating the Center for Medicare and Medicaid Services’ reimbursement reductions; matters are proceeding toward mediation and arbitration.
  • Representing 170 hospitals nationwide before the Medicare PRRB in challenges to CMS’ historical calculation of IPPS rates dating to federal fiscal year 1986. The matter, valued at hundreds of millions of dollars, seeks correction of longstanding reimbursement underpayments and remains pending before the PRRB.
  • Representing over 300 hospitals nationwide in Medicare PRRB and federal court litigation challenging CMS’ application of the rural floor budget neutrality factor affecting federal fiscal year 2024 wage indices. The firm’s team secured expedited judicial review and filed suit in the U.S. District Court for the District of Columbia seeking declaratory relief and damages.
  • Representing a clinical director subpoenaed by the New Jersey State Commission of Investigation in a wide-ranging inquiry into addiction treatment facilities involving alleged improper referrals, ownership structures, and quality-of-care concerns, with potential industry-wide reimbursement implications in the hundreds of millions of dollars.
  • Represented a coalition of New Jersey hospitals in a $300 million constitutional challenge to the State of New Jersey’s charity care and Medicaid reimbursement regime, defending the hospitals’ takings claims through summary judgment, Appellate Division review, and New Jersey Supreme Court proceedings, resulting in published decisions affirming dismissal of the claims. The hospitals filed a petition for certiorari with the Supreme Court of the United States, which was denied.

Published Cases

  • In Rahway Hospital v. Horizon Blue Cross Blue Shield (2005), argued on behalf of amicus curiae New Jersey Hospital Association before the New Jersey Appellate Division, supporting reversal of an administrative ruling concerning healthcare reimbursement, resulting in a published decision overturning the agency’s interpretation. 
  • In United States ex rel. Quinn v. Omnicare, Inc. (2004), represented Omnicare in a False Claims Act qui tam action in the U.S. Court of Appeals for the Third Circuit alleging fraudulent billing and reimbursement practices, securing affirmance of summary judgment and dismissal of all claims.   

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