Healthcare Reimbursement Compliance and Disputes

Healthcare payment is extraordinarily complicated, and the applicable Medicare and Medicaid rules have far-reaching effects on the financial and business operations of healthcare providers. At Troutman Sanders, we take a holistic approach to legal services and strive to understand the full context of our clients’ activities and objectives. For example, our healthcare attorneys regularly deliver comprehensive guidance on payment-for-services rules while also providing targeted counsel on matters such as structuring deals or transactions.

We work closely with a client’s internal claims processing and payment monitoring infrastructure and the consulting firms that provide services to healthcare providers related to these activities. Complementing these existing resources, we focus on the legal, compliance and policy implications of reimbursement and claims processing.

We advise clients in numerous areas, including:

  • Audit-related, large-scale denial of claims;
  • Medical necessity claims denials;
  • Incorrect coding denials; and
  • Medicare and Medicaid billing rules related to documentation, staffing, site of care or level of care.

  • Advising a rehabilitation hospital on its negotiation of a participation agreement with a large health plan, with specific emphasis on the reimbursement rates related to various place of service codes;
  • Representing a client in a study of a correct-coding initiative for clinical labs, outpatient services and observation beds, to determine whether a voluntary disclosure is needed;
  • Evaluating the provider-based rules for specific clinical programs, to determine whether the enhanced payment for provider-based status is available;
  • Advising end-stage renal disease (ESRD) facilities on enhanced payment from Medicare based on the specific exclusions available, such as isolated and essential; and
  • Advising clients on reimbursement issues that arise during the sale of healthcare facilities, including assignment, lock boxes and other concerns.