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Health Care Compliance and Reimbursement

Spencer Fane Health Care attorneys help health care providers and organizations in the health care industry navigate the complex federal laws and other requirements that govern compliance and reimbursement, so that our clients can keep their focus on patient care.

The well-rounded experience of our team extends beyond the legal industry, including attorneys who have managed a medical practice, served as in-house counsel with health care companies, earned advanced degrees in areas like health care administration, and maintain certifications in medical coding and health information management. We bring an understanding of the challenges our clients face in operations, allowing us to provide practical guidance on how to effectively implement compliance and reimbursement best practices and policies to achieve the client’s organizational objectives.

Compliance Services

While the Spencer Fane team has a successful track record representing clients in compliance audits and disputes, our attorneys aim to minimize these issues through thorough, proactive preventative measures. We aim to keep health care organizations in compliance with federal laws like the Stark Law, Anti-Kickback Statute, EMTALA, Travel Act, False Claims Act and HIPAA along with their state-law counterparts.

To achieve these preventative goals, our team takes time to understand the organization through analyzing existing policies and procedures, training, risk analysis, records, and agreements. This analysis provides the necessary foundation to assess compliance with state and federal requirements, identify risks and opportunities, and provide guidance to leaders on how to strengthen their programs.

Our experience includes providing structural analysis to health care providers for joint ventures, data sharing arrangements, and other collaborative models. We typically assess compliance in the early stages of an agreement to build a proper foundation and continue to work with the organization and provide guidance on implementation and maintenance of the strategic plan.

Reimbursement Services

Our attorneys help health care organizations structure their services in a manner that maximizes their reimbursement, while minimizing the risk of audits and allegations of non-compliance. We also educate clients on how to best comply with reimbursement requirements related to Medicare and Medicaid conditions of payment, coverage, physician supervision, and documentation policies of third party payers, and pre- or post-payment review, denial, and appeal. When an overpayment issue arises, we collaborate with the organization to develop a response and resolution strategy that complies with the obligations of the applicable payer or government agency.

Spencer Fane also has extensive experience in guiding clients through often-difficult audit processes or reimbursement disputes related to overpayment fraud.

Representative Experience

  • Performed audit of hospital’s compliance program and assisted hospital with creation and implementation of a new compliance program.
  • Assisted hospital with identifying and voluntarily refunding a significant overpayment from Medicare resulting from inadequate physician supervision of certain therapeutic services.
  • Assisted hospital in reviewing its physician compensation arrangements and voluntarily self-disclosing to the Centers for Medicare and Medicaid Services any physician compensation arrangement which did not comply with the Stark Law.
  • Analyzed state corporate practice of optometry and fee-splitting prohibitions for a national organization considering opening optometry practices in such states to confirm that its business structure did not violate such prohibitions.
  • Assisted hospital in analyzing and correcting the operational procedures in its Emergency Department as a result of a notice received from a state surveyor that the Emergency Department had violated EMTALA.
  • Defended a hospital in a federal investigation related to facility claims where the underlying procedures were determined to not meet medical necessity requirements.
  • Developed corporate compliance programs for hospitals, physician practices, and other healthcare organizations in accordance with guidance from the OIG, including drafting policy, training staff, and implementing audit and resolution processes.
  • Developed a structure for physician-hospital integration that involved analysis of compliance with Stark and Anti-Kickback as well as the Medicare, Medicaid, and commercial payer reimbursement rules for the service lines involved.