Reimbursement, medical necessity and the medical staff.

Healthcare disputes have formed a continuous part of the practice preceding this work for more than fifteen years, on both sides of the payor-provider relationship and on both sides of enforcement.

Representative experience

• Lead defense counsel in a pending federal healthcare enforcement action seeking over $150 million, involving Medicare, TRICARE and private-insurance claims, medical necessity, and a claims record exceeding 25 gigabytes
• Lead counsel for the corporate defendant in the largest healthcare fraud prosecution ever brought in its federal district, spanning trial, corporate monitorship and appeal
• Lead counsel for a director of a national hospital system in a director-and-officer action brought by a bankruptcy trustee, over $50 million in controversy
• Lead plaintiff counsel for a university health-sciences program in Medicare-compliance litigation, with a parallel government investigation
• Defense counsel in a two-week hospital peer-review and credentialing hearing

Issues

• Medical necessity and documentation sufficiency; extrapolation across claims populations
• Medicare, Medicaid, TRICARE and commercial payor reimbursement
• Medical staff corrective action, clinical privileges and credentialing
• False Claims Act, Anti-Kickback Statute and healthcare fraud enforcement
• Governance, fiduciary duty and insolvency in healthcare entities