Medicare and Medicaid Reimbursement and Managed Care

Medicare and Medicaid Reimbursement: Our Medicare and Medicaid Reimbursement services fall into three categories:

General reimbursement counseling: Our Health Care Industry Team has represented numerous hospitals, skilled nursing facilities, physicians, and other providers and suppliers in Medicare Parts A and B reimbursement, commercial reimbursement, research payments, and related matters.

Appeals: Our attorneys provide some of the most sophisticated Medicaid and Medicare reimbursement appeal, settlement negotiation, and dispute resolution services in the country, having handled hundreds of payment disputes on behalf of providers, as well as payors. Some of our attorneys have had the opportunity to work for the CMS as payment counsel, while others have advised commercial payors on payment disputes. Thus, we have broad perspectives when collaboratively approaching your appeal and dispute resolution needs.

New Medicare developments: We are very familiar with new developments in the Medicare and Medicaid arena because of our daily national work. For example, Foley has carefully monitored the creation and development of the Medicare Recovery Audit Contractor (RAC) program. We have been engaged to assist hospitals in responding to denials of inpatient rehabilitation services issues by a contractor under the RAC program. The RAC contractor has denied numerous hospital stays that were paid by the Medicare program several years ago, based upon its conclusion that the services, which primarily involve hospital stays in connection with joint replacements, were not medically necessary. The RAC is now implemented for Medicare in all states. In addition, state Medicaid programs are now required to implement RAC programs (with contingency fee compensation) nationally. Commercial payors are similarly invested in this methodology. Foley has represented many clients in RAC response strategy and appeals. We also have advised clients on successful suppression of claims voluntarily refunded on an extrapolated basis from the RAC data warehouse. We continue to be closely involved with developments in the RAC program and its impact on clients. 

Managed Care: Our attorneys work with all types of payors, including health maintenance organizations (HMOs), health plans and health insurers, Medicare Advantage (MA) plans, Medicare prescription drug plans (PDPs), Medicaid state waiver managed care plans (Waiver Programs), self-insured employers, third-party administrators (TPAs), preferred provider organizations (PPOs), exclusive provider organizations (EPOs), workers’ compensation managed care organizations (HCOs), state-sponsored universal coverage programs (such as the 2006 Massachusetts Health Care Reform Law), and a variety of other managed care entities.

Our provider clients include institutional and professional providers, multi-specialty medical groups, provider-sponsored PPOs, physician-hospital organizations (PHOs) and PHAs, nonprofit medical foundations and clinics, IPAs, provider network management companies and intermediaries, brokers, disease management (DM) companies, utilization review organizations, and peer review agents. We also can assist you with non-contracted-provider payment practices, “silent PPOs,” and tiered networks. With a wide range of business, reimbursement, regulatory, contracting, operational, and compliance experience, our attorneys are knowledgeable in all areas of legal practice relevant to the managed care industry.