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Reimbursement

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In health care as in no other industry, the most essential and seemingly obvious of business activities – getting paid for your services – requires adherence to a series of statutes, regulations and policies established by Congress, state legislatures, federal and state agencies, contractors and private insurers.

Practice Overview

Overview

In health care as in no other industry, the most essential and seemingly obvious of business activities – getting paid for your services – requires adherence to a series of statutes, regulations and policies established by Congress, state legislatures, federal and state agencies, contractors and private insurers. And if things go wrong, auditors lie in wait, authorized to review company policies and claims and recapture payments years after a product or service was delivered.

The job of Baker Donelson's Reimbursement Team is to ensure that our clients get paid. In order for that to happen, providers must, first and foremost, follow the rules. Our attorneys work closely with clients to develop sound policies and procedures so they consistently meet the requirements of Medicare, Medicaid, Veterans Administration health programs and private payers, conducting internal audits as necessary to identify and correct flaws.

Baker Donelson helps a wide range of health care entities on reimbursement issues, including hospitals, physicians, medical academic centers, home health agencies, pharmacies, skilled nursing facilities, urgent care facilities, durable medical equipment suppliers and independent diagnostic testing facilities.

The questions and concerns that arise when dealing with reimbursement are interwoven with legal questions involving corporate structure and governance, privacy, compliance, audits, public policy, taxes and even white collar crime. Baker Donelson's team approach and our deep, broad knowledge of both health care law and business allow us to effectively represent clients on a range of issues, including the following:

  • Assist providers in obtaining initial enrollment in Medicare, Medicaid and other payers
  • Coordinate Medicare change of ownership (CHOW) events for hospital and ancillary facility acquisitions, including 855 filings, certification surveys and cash flow considerations
  • Assure that relationships, transactions, and structural changes comply with the Anti-Kickback Statute, Stark law, HIPAA and various other requirements on the federal and state levels
  • Work with appropriate entities to obtain proper coverage, coding and reimbursement for new devices, products and services. This includes working with the Centers for Medicare and Medicaid Services (CMMS) on the development of a National Coverage Determination impacting a particular product
  • Negotiate major contracts with national plans on behalf of hospital systems, physician groups and ancillary service providers
  • Work with hospitals that provide extensive non-reimbursed care to obtain disproportionate share (DSH) payments, including complicated situations where a border hospital provides services to residents of another state
  • Collaborate with Baker Donelson's Government Relations and Public Policy to work to change or clarify laws, regulations and policies that are vague or unfair to clients

Even the best companies occasionally run into problems. And when that happens, Baker Donelson helps clients more effectively navigate audits, including those by Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs), Zone Program Integrity Contractors (ZPICs) and the Office of Inspector General (OIG).

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