Payment & Claim Disputes

Clark Hill lawyers have personally handled literally hundreds of claims in administrative hearings adjudicating issues of medical necessity, claim denial, rate changes, claim submittal issues, waiver, estoppel, and contract interpretation.

Clark Hill lawyers consult directly with clients regarding development of claims and payment policies and procedures.

Clark Hill attorneys represent clients in state and CMS sanctioned audits.

Experience

PROCUREMENT

● Representing behavioral health care providers challenging biased governmental procurement
● Challenging and defending procurement contracts for Medicaid and Medicare services
● Responding to RFP for Medicaid and Medicare services
● Consulting regarding Integrated Model RFP submittals

LONG TERM CARE ADMINISTRATION

● Representing clients in the formation, organization, merger and acquisition of long term care facilities
● Negotiating contracts with Medicaid and Medicare managed care companies
● Negotiating rate revisions on behalf of long term care entities
● Handling claim disputes on behalf of long term care facilities with private and government payors
● Participating in drafting of licensure survey plans of correction and licensure appeals
● Preparing medical director agreements
● Handling state agency self-reporting issues for resident abuse and neglect
● Providing consultation for day-to-day operating activities as general counsel

FRAUD/ABUSE

● Representing providers regarding alleged violations of federal and state false claims acts
● Preparing and delivering presentations to clients regarding methods to avoid and mitigate audit inquiries
● Representing providers in state and federal audits
● Representing clients in Stark and Anti-kickback analysis in hospital/physician arrangements, home health and long term care arrangements with physicians, vendors, and suppliers

ACQUISITIONS AND MERGERS

● Facility acquisitions and vertical integration
● Creating viable third Party Administrators
● Horizontal integration of behavioral health providers
● Reorganization of multi-specialty groups
● Consulting on information technology agreements
● Preparing employee leases and management service contracts
● Reviewing, analyzing, and drafting facility policy and procedure manuals

LICENSING

● Represent physicians, nurses, nurse practitioners, BH providers and facilities in claims against licenses, renewals and reporting
● Licensing of new facilities
● Represent facilities in the appeal of adverse action determinations

PAYMENTS AND CLAIMS DISPUTES

● 35 years’ experience in Medicaid and Medicare claims disputes
● Representing providers in literally thousands of administrative hearings for denied claims regarding issues of medical necessity, short-pay, prior and continued authorization, recoupment, rate changes, inaccurate submittals, waiver and estoppel
● Consulting with clients for development of claim submittal, policies and procedures
● Representing behavioral health providers in Medicare Advantage and ERISA claim disputes
● Counsel and advise clients on the development and growth of international partnerships and medical travel

FACILITY/PHYSICIAN RELATIONS

● Creating employment agreements tailored to tele-psychiatry
● Draft independent contractor agreements for (Locum tenens)
● Establishing physician group contracts
● Constructing hospital based physician services agreement including laboratory, emergency department, etc.
● Develop outpatient psychiatric service clinics
● Develop psychiatric unit
● Management and Co-Management Agreements

COMPLIANCE AND REGULATION

● Created a workable and affordable Behavioral Health Care Compliance Institute
● Real time knowledge of HIPAA rules, policies and procedures
● Counseling and advising clients regarding patient confidentiality
● Advising clients regarding OIG self-disclosure requirements
● Completing and complying with CMS Audit requirements

INSURANCE POLICY LITIGATION

● Representing behavioral health providers in coverage issues, reinsurance issues and policy language disputes
● Handling tenders of defense and demands for contractual indemnification
● Acting as counsel of choice for behavioral health providers in medical negligence lawsuits

PHARMACEUTICAL

● Consulting regulatory monitoring requirements
● Supplying medical malpractice defense regarding misuse of pharmaceuticals

IMPLEMENTATION OF STATUTORY AND REGULATORY SCHEMES

● Supplying real time advice regarding the highly nuanced CMS regulatory scheme
● Creating practical solutions for implementation of internal policies to comply with federal and state statutes, regulations and procedures

STRATEGIC ADVICE AND COUNSEL

● Planning and implementing integration strategies to help clients stay relevant in the world of health care reform
● Developing and negotiating joint venture and other collaborative ventures
● Developing and negotiating third party payor agreements
● Counsel and assist clients with development and application for demonstration project funding
● Counsel and advise clients on servicing dual-eligible population
● Counsel and advise clients on development and participation in Accountable Care Organizations, Patient Centered Medical Homes and other alternative deliver models

PREMISES LIABILITY

● Providing defense to behavioral health facilities relating to patient and employee injuries

ERRORS AND OMISSIONS DEFENSE

● Medical malpractice—psychiatric
● Medical malpractice—BH professionals
● Medical malpractice—psychiatric and integrated clinics
● Medical malpractice—psychiatric hospitals
● Medical malpractice—long term care facilities
● Medical malpractice—Psychiatric Urgent Care
● Medical malpractice—Psychiatric Emergency Care—EMTALA
● Directors and officers liability claims

MANAGED CARE CONTRACTING

● Preparing risk contracts
● Creating risk pool arrangements
● Negotiating skilled nursing facility and free standing psychiatric clinic managed care contracts
● Drafting managed care contracts for providers of Medicaid and Medicare services
● Development of managed care provider networks and administrative service organizations for MCPNS

ERISA LITIGATION

● Handling ERISA preemption litigation
● Handling benefit coverage cases to ensure providers are paid
● Consulting on COBRA issues
● Pursuing claims payment against Plan Administers

LIENS—MEDICAID AND MEDICARE-STATE STATUTORY SCHEMES

● Pursuing lien rights on behalf of Medicaid and Medicare providers
● Pursuing state statutory and lien statutes for behavioral health and acute care providers
● Consulting regarding contract obligations for providers’ obligations to pursue CMS and State liens

LABOR AND EMPLOYMENT

● Advising and consulting clients regarding criminal history/background checks for behavioral health care providers, investigations regarding allegations of discriminatory/ retaliatory conduct
● Preparing personnel handbooks and policy manuals
● Consulting on FMLA issues and other employment related issues including EEOC appeals and lawsuits
● Preparing and pursuing appeals to state and federal courts from administrative decisions
● Advising clients regarding wage and labor issues and representing them in DOL investigations

CREATION OF NON-PROFIT CORPORATIONS

● Creating non-profit corporations to take advantage of grants and other funding
● Expertise includes tax analysis

STATE AND FEDERAL ADMINISTRATIVE HEARINGS AND APPEAL

● Litigating for claims payments
● Litigating in state and federal administrative hearings
● Trying cases in state and federal court
● Representing clients in Arbitration
● Conducting Mediation

UBROGATION/INDEMNIFICATION

● Pursuing third party liability claims
● Pursuing statutory and regulatory liens
● Pursuing secondary payors for unpaid claims

Articles
Behavioral Health Care Law ChartOpen MindsRelationships & the Law Today: Married on Sunday, Fired on Monday: Recent Developments in Employment Law - September 21, 2016Top 10 Health Law Issues 2016 by AHLA Connections Gun safety: HIPAA change allows providers to report on some mentally ill patients Managed Care Litigation and The Affordable Care Act, GPSolo Magazine (ABA) (March/April 2015)Patient-Physician Confidentiality: 'Til Death Do Us Part?Thinking of Investing In, or Renting Space In, an ASC? Have You Taken Compliance into Consideration?How to Legally Break Up With Your PatientAdvocates Want State to Get Serious on Gay BiasHIPAA Omnibus Rule: What Anesthesiologists Must Do NowHospital Incentives to PhysiciansManagement and Third-Party Billing CompaniesReporting Post-Operative Pain Management Procedures in 2013A Survey of State Prompt Pay Laws, Part IISo You're Thinking of Getting into the Business of Healthcare? Here Are the Top 5 Things You Need to KnowWhat You Need to Know About the Supreme Court's Decision on Health Care ReformSocial Media Policies: Do I Really Need One?Five Steps to Protect Your Organization from HIPAA AuditsThe Required Hospital Standard Charge Publication That You Probably Missed, American Health Lawyers Association Hospitals & Health Systems RXAnesthesiologists Should Beware of HIPAA AuditsBehavioral Health Care Institute - The Holidays: Gifting and Gift PoliciesBehavioral Health Care Institute - Michigan Attorney General Announces Fraud Charges Against Southeast Michigan Mental Healthcare Providers
Presentations
Webinar: Entrepreneurial Medicine: Opportunities to Enhance Your Practice and Bottom LineWebinar: Physician Compensation Reform: How You Will Get PaidPhysician Webinar Series
Media
Family Practice News: How Proposed Patient Substance Use Privacy Rule Impacts Physicians – March 10, 2016