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.