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Regulatory Appeals

In the highly regulated healthcare environment, providers frequently encounter adverse decisions from state and federal agencies, ranging from Medicare and Medicaid payment denials to licensing sanctions and other enforcement actions. With an in-depth understanding of the complex administrative landscape, requirements and legal precedents needed to effectively challenge unfavorable regulatory determinations, Greenbaum provides comprehensive legal services dedicated to representing healthcare providers in regulatory appeals.

We represent clients in state regulatory appeals before the Office of Administrative Law, New Jersey Superior Court, Law and Appellate Divisions, and the New Jersey Supreme Court. Our work includes the defense of licensed healthcare professionals in appealing adverse decisions related to license suspension, revocation, probation or fines handed down by New Jersey's various professional licensing boards, including the Board of Medical Examiners (BME), Board of Nursing, and Board of Pharmacy.

We assist clients with appeals related to the denial of license reinstatement applications. In addition, we represent healthcare facilities and providers in challenging adverse decisions by the New Jersey Department of Health regarding the issuance or denial of Certificates of Need for new facilities, services, or significant capital expenditures, and handle administrative agency appeals from other state and federal healthcare-related agencies that impact a provider's operations, such as those related to facility licensure, surveys, or regulatory compliance penalties.

Greenbaum is a leading resource for Medicare and Medicaid reimbursement appeals, including overpayment appeals, medical necessity denials, coding and billing disputes, and enrollment and credentialing denials. We assist a wide range of healthcare entities and professionals in challenges to adverse regulatory determinations, including hospitals and health systems, physician practices, ambulatory surgical centers, long-term care facilities, home health agencies, pharmacies, and individual licensed professionals.

Representative Matters

  • 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 173 hospitals nationwide in Medicare Provider Reimbursement Review Board (PRRB) proceedings challenging CMS’ exclusion of Section 401 hospital wage data from rural floor reimbursement calculations. This Medicare reimbursement matter, valued in the hundreds of millions of dollars, remains pending before the PRRB.  
  • Represented a New Jersey healthcare system and its Chair of Surgery in litigation brought by a trauma surgeon challenging a summary suspension of medical staff privileges. Following reinstatement through internal proceedings, the firm continued to defend the client in this $2.4 million action, which settled before trial.  

Of Interest