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Reimbursement and Payment

Overview

The OMW healthcare team weaves together its intimate healthcare operational knowledge with its deep familiarity with healthcare reimbursement systems and payment rules. We assist health systems, hospitals, physicians, ambulatory surgical facilities, behavioral health providers, community health centers, imaging facilities, laboratory facilities, and other providers with ensuring that transactions and other initiatives are structured to maximize reimbursement in a legally compliant manner. In furtherance of this service to its clients, OMW healthcare lawyers have significant experience working with, and adverse to, payors, government agencies, auditors, surveyors, and accreditation bodies. The OMW healthcare team has extensive experience guiding clients through responding to payment inquiries and aggressively pursuing reimbursement through all necessary channels and levels of appeal. We routinely assist our healthcare provider clients with the following:

  • Medicare Enrollment (CMS Form 855, CHOW – change of ownership), provider survey, licensure, and accreditation requirements
  • Review and updates regarding historical Medicare Local Medical Review Policies (“LMRP’s”), Local Coverage Determinations (LCD’s), and National Coverage Determinations (“NCD’s”).
  • Clinically Integrated Network/Medical Home/Shared Savings formation and development
  • Appeals of Enrollment and Payment Issues, all levels – Medicare Administrative Contractor, CMS, Medicare Departmental Appeals Board, Medicare Provider Reimbursement Review Board, State and Federal Court
  • Defending Providers in administrative proceedings to exclude them from participation in government healthcare programs
  • Responding to inquiries and audits from Office of Inspector General, Department of Justice, Medicaid Fraud Control Units, Medicare Administrative Contractors (“MAC”), Recovery Audit Contractors (“RAC”), Zone Program integrity Contractors (“ZPIC”), and Unified Program Integrity Contractors (“UPIC”)
  • Negotiate, draft, and assist clients to operationalize various managed care and other strategic initiatives among healthcare payors and providers
  • Assist clients with returning any identified overpayments to appropriate payors
  • Assist clients with obtaining Medicare Disproportionate Share payments to which they are entitled
  • Work directly with governments and commercial payors to help influence the development of laws, payment rules, and other policies

Maximizing reimbursement and maintaining legal compliance often involves a broad array of complex legal issues. OMW Healthcare team lawyers routinely obtain support from other OMW practice areas such as tax, litigation, governance, audits and investigations, compliance and mergers and acquisitions.

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