Federal healthcare programs, namely Medicare and Medicaid, are the largest purchasers of healthcare services in the U.S. Ensuring coverage and reimbursement under these programs is of critical importance to healthcare providers. At Jackson Walker, we provide sophisticated counsel to our healthcare clients on the complex coverage and reimbursement issues arising under Medicare, Medicaid, and other government health programs. Healthcare clients need attorneys with both the experience and the technical expertise to guide them successfully through the complexity of these regulatory schemes. We pride ourselves on our ability to develop creative and effective processes and solutions for our clients thanks to our thorough knowledge and understanding of these multifaceted programs and how they operate within the healthcare industry.

Our attorneys work closely with clients to navigate change of control issues, overpayment liabilities, reimbursement standards, Medicare participation rules, and other issues related to reimbursement. We help clients successfully present information to secure coverage of new types of services, practice modalities, and innovative procedures that improve the provision of care offered to patients. We also help clients identify circumstances when a compliance failure has created overpayment liability or triggered self-reporting obligations and advise on each accordingly. We design, improve, and implement cost-reporting, pricing, billing, and reimbursement policies to maximize coverage and reimbursement for our clients. Lastly, we assist clients in formulating responses when faced with audit requests and inquiries and, where appropriate, challenging overpayment determinations through administrative appeals.

  • Represented three separate national healthcare systems having a total of 67 hospitals in the settlement of over 21 separate PRRB group appeals on floor budget neutrality issue with the DOJ and CMS Office of General Counsel for over $50 million.
  • Represented hospital clients in matters involving the Centers for Medicare and Medicaid Services and the Provider Reimbursement Review Board (PRRB).
  • Represented healthcare providers in appeals of Medicare/Medicaid terminations, exclusions, and appeals of state and federal civil monetary penalties and other sanctions
  • Represented healthcare clients in administrative proceedings involving Medicare/Medicaid reimbursement such as appeals of audit determinations by Medicaid Recovery Audit Contractors (RACs) and Medicaid Integrity Contractors (MICs).
  • Represented clients accused of civil Medicare or Medicaid fraud and abuse.
  • Represented clients in investigations by the Texas Health and Human Services Commission Office of the Inspector General.
  • Represented three separate national healthcare systems having a total of 67 hospitals in the settlement of over 21 separate PRRB group appeals of the rural floor budget neutrality issue with the DOJ and CMS OGC for over $50 million.
  • Represented a Texas hospital district in the settlement of its PRRB regarding DSH reimbursement.
  • Represented a national for-profit hospital company specializing in rural providers in settling a group appeal for six of its hospitals for acquisition interest expense before the PRRB for over $10,000,000 aggregate Medicare reimbursement.
  • Represented a national for-profit hospital company specializing in rural providers in a successful appeal for one of its hospitals before the PRRB and CMS Administrator of several Medicare reimbursement issues recovering over $2 million Medicare reimbursement.
  • Represented a California hospital system in a successful PRRB appeal and CMS Administrator Decision for reimbursement under an improperly denied SNF exemption with a reimbursement effect of several hundred thousand dollars for each of several cost reporting periods.
  • Represented a Michigan hospital system in the favorable settlement of numerous PRRB appeal reimbursement issues with a cumulative favorable reimbursement effect of several million dollars.
  • Represented a national for-profit hospital company specializing in rural providers in the favorable settlement of numerous PRRB appeal reimbursement issues with a cumulative favorable reimbursement effect of several million dollars.
  • Represented a Texas hospital district in its Medicare appeals before the PRRB and Federal District Court regarding changing the useful lives of two of its hospital facilities.
— Client Results

Jackson Walker Secures Favorable Ruling in Medicare Reimbursement Appeal

  • Medicaid RAC audit counseling, defense, and appeals
  • ZPIC Audit counseling, defense, and appeals
  • Medicare PRRB representation and appeals
  • Resolution of Medicare/Medicaid and third-party payment billing and coding issues
  • Response to inquiries and investigations by the Centers for Medicare and Medicaid services
  • Medicare provider reimbursement disputes
  • Assistance in preparation of required documentation for coverage and billing
  • Payor relations, audits, and appeals
  • Advice regarding billing, coding, and coverage issues including those related to diagnostic services, physician reassignment, supplier enrollment, and non-physician practitioners
  • Advice regarding cost-reporting issues and provider-based status
  • Structuring of delivery systems that comply with applicable regulations