Government and Commercial Coding, Coverage, and Payment

Overview

Coverage and payment issues in the health care industry are extremely complex for many organizations. Epstein Becker Green has decades of experience representing health care clients in third-party coding, coverage, and payment/reimbursement issues from state and federal governmental sources.

We have many attorneys with in-depth knowledge about all types of government health programs. At the federal level, we assist clients with a full spectrum of federal health program issues, including Medicare, Medicaid, Tricare (formerly CHAMPUS), and the Federal Employees Health Benefits (FEHB) Program. At the state level, we assist clients with state Medicaid and other state rate-setting matters, state payor systems, and other state programs, such as high-risk pools for the chronically ill.

Our Government and Commercial Coding, Coverage, and Payment Group consists of attorneys who focus on government program coding, coverage, and payment/reimbursement matters; qualification for participation in federal and state health programs; and obtaining facility licenses and/or certificates of need. We also counsel clients on the requirements for operating and delivering health services to governmental programs and assist clients in maintaining corporate compliance with these highly regulated health programs.

Services to Meet Your Needs

Epstein Becker Green provides complete legal support for health care organizations related to third-party payors. Our services include:

providing representation before the Medicare program, the Medicaid program, Tricare, the FEHB Program, and the U.S. Public Health Service;
providing representation before state rate-setting boards and state payor systems;
serving as due diligence counsel to determine a health care organization's compliance with government health program requirements;
serving as legal counsel for qualification submissions for participation in federal and state health programs;
preparing documentation and submissions for state facility licenses and certificates of need;
providing comprehensive legal services regarding participation requirements in government health programs, including participation in the Medicare Advantage program and Medicaid managed care programs;
appealing payment denials and overpayment determinations for providers and suppliers under all government health programs;
providing legal reviews of new and proposed corporate structures for impact on eligibility for government payments;
litigating disputed denials and payment methodologies;
advising on pharmaceutical rebate and discount issues under state and federal rebate laws, including the Medicaid Drug Rebate Act/Veterans Health Care Act;
providing representation in connection with coding, coverage, and payment issues for new drugs, devices, or services; and
providing guidance to health care clients, billing technology entities, and industry/professional groups on the No Surprises Act, including its challenging interaction with state balance billing laws.