Reimbursement

There can be no doubt that the statutes and provisions in question, involving the financing of Medicare and Medicaid, are among the most completely impenetrable texts within human experience. . . . not only are they dense reading of the most tortuous kind, but Congress also revisits the area frequently, generously cutting and pruning in the process and making any solid grasp of the matters addressed merely a passing phase.  Rehabilitation Ass’n of Va., Inc. v. Kozlowski, 42 F.3d 1444, 1450 (4th Cir. 1994) (Chief Judge Sam J. Ervin, III).

Federal health care programs, including Medicare and Medicaid, constitute the largest purchasers of health care services in the country; therefore, issues of reimbursement and coverage under these programs are of critical importance to health care providers. PPSV has considerable experience advising health care organizations and practitioners such as hospitals, physicians and physician groups, nursing homes, ancillary service providers and others regarding all aspects of reimbursement and coverage.

The complexity of the federal Medicare and Medicaid regulatory schemes demands practitioners with extensive experience and technical expertise.  We pride ourselves on our thorough knowledge of the intricacies of these multifaceted programs, in addition to our grasp of the broader implications of reimbursement issues.  Our knowledge and perspective come from our long experience in this practice area; members of the firm’s reimbursement practice have been involved in the field since the establishment of the Centers for Medicare and Medicaid Services (formerly the Health Care Financing Administration) in the 1970s.  Our attorneys have handled significant cases before administrative agencies, as well as state and federal courts across the country, including the US Supreme Court.

MEDICARE PAYMENT

Health care entities of every size and description look to PPSV for solid, grounded advice on the full range of issues related to Medicare payment and coverage matters.

PPSV attorneys have substantial expertise relating to Medicare reimbursement of hospitals, skilled nursing facilities, and other institutional providers, including the following areas:

• Prospective payment systems
• Wage index 
• Disproportionate share hospital payments
• Direct graduate medical education payments
• Indirect medical education payments
• Reasonable cost payment
• Bad debts
• Organ acquisition costs
• Cost report appeals, including Provider Reimbursement Review Board and Medicare Geographic Classification Review Board
• Coverage denial appeals

PPSV also has significant experience with Medicare payment for the services of physicians and non-physician healthcare practitioners. Our attorneys advise and represent individual physicians, group practices, and professional organizations on a wide array of Medicare matters, including:

• Physician fee schedule issues, including the assignment of relative value units and development of practice expense and work data
• Coding and documentation practices
• Billing and claims processing issues, including reassignment rules
• Compliance with CMS regulations and policies
• Carrier audits and investigations
• Administrative advocacy before federal agencies

PPSV attorneys render valuable guidance and input to health care organizations that participate in CMS demonstration projects.  We assist such organizations throughout the country in all compliance issues, applications, contract review, and reporting mechanisms for Medicare, Medicaid and state Children’s Health Insurance Programs’ reimbursement and fee recovery. In addition, as a result of our significant experience with governmental entities vis-à-vis health care providers, we can assist with the presentation of captured clinical care data and related information, to influence support for coverage of new types of services, practice modalities and innovative procedures that favorably affect the provision of care. 

MEDICAID PAYMENT

PPSV attorneys have broad experience with Medicaid program requirements under federal and state laws and regulations, as well as Medicaid State plans and guidelines regarding reimbursement, eligibility, and coverage.

Our attorneys have handled Medicaid matters involving prospective payment systems, disproportionate share hospital payments, Resource Utilization Groups (RUGs), income ceilings for eligibility, specific treatment groups, and fixed payment amounts, including reimbursement appeal issues.  We are also well versed in the particular rules, guidelines and pricer formulas for nursing homes, home health agencies, long-term care facilities and similar provider facilities requiring special treatment under Medicaid rules.  Clients look to PPSV for representation in matters relating to federal medical assistance percentages, provider taxes, assistance with state inter-governmental transfers, and work on state and federal demonstration project contracts, eligibility and documentation requirements.

COVERAGE

PPSV works closely with healthcare providers in advocating Medicare coverage of new services and technologies that increase patient access, improve medical care, and reduce costs.  Our attorneys are very knowledgeable regarding the Healthcare Common Procedure Coding System (HCPCS) and assist with requests for new CPT and HCPCS codes and modifications to existing codes.  Additionally, PPSV furnishes advice on national and local coverage determinations and exclusions and represents clients in challenging coverage denials, including administrative appeals.

SURVEY AND CERTIFICATION

Health care providers turn to PPSV for guidance on the complex survey and certification process and for advice on compliance with standards set at both the state and federal levels.  We represent clients facing adverse actions, terminations, and all types of compliance issues involving the Medicare Conditions of Participation and related certification and licensure standards.   

We assist our clients in responding to statements of deficiencies and in developing acceptable plans of correction that meet program requirements and result in optimal performance.  We provide experienced counsel throughout the appeals process, including hearings before Administrative Law Judges and appearances before the Departmental Appeals Board and other administrative hearing bodies. 

MANAGED CARE

Our attorneys help health care organizations correctly interpret provisions relating to application procedures and contract requirements of the Medicare Advantage program, including new guidelines set forth by the Medicare Prescription Drug, Improvement and Modernization Act that mandate new bidding procedures, contractual changes and health plan options.  We represent health care entities operating coordinated care plans, and have worked with them to achieve compliance with all contractual obligations and applicable federal statutes, regulations and policies.  We are experienced in interpreting and applying the Medicare fee-for-service Hold Harmless provision, and extremely knowledgeable regarding all conditions and requirements needed to waive or reduce penalties.