Handling Medicare and Medicaid Overpayments: Provider Refund and Reporting Obligations, Avoiding Penalties

Ms. Gordon’s practice is focused on managed care litigation, fraud and abuse matters, inclusive of False Claims Act litigation, managed care contract review, and compliance advising. She has handled a wide array of reimbursement disputes with both commercial and government payors, for both contracted and non-contracted providers. Such disputes also include challenging and responding to payor audits, recoupment requests, and investigations. Ms. Gordon also frequently handles Medicare appeals and ALJ hearings, Targeted Probe and Education audits, Comprehensive Error Rate Testing denials and appeals, and Uniform Program Integrity audits. She routinely defends providers in healthcare fraud and abuse matters ranging from assistance and strategy with responses to Civil Investigative Demands and subpoenas issued by DOJ, OIG, the Department of Insurance, and other governmental entities, to defending providers in qui tam relator actions, False Claims Act actions, and related actions brought under various state laws such as the Insurance Fraud Prevention Act. She also works closely with clients on managed care contract review and negotiation, as well as compliance advising and internal policy development. Ms. Gordon also has substantial experience in the long-term care space, related to both fraud and abuse matters, as well as citation appeals. She has also regularly handled internal audits and investigations and government agency audits, for a variety of healthcare provider types. Ms. Gordon’s practice comprises both providing effective representation for clients in disputes and providing strategic counsel and guidance concerning regulatory issues and actions. With respect to the former, she has handled dozens of matters through arbitration, mediation, before administrative panels, and in courtroom litigation both at the state and federal level.

Ms. Banks focuses her national practice on advising hospitals, health systems and other healthcare providers and suppliers on the full range of Medicare and Medicaid compliance and reimbursement issues. She also helps clients navigate the complexities of healthcare delivery reform and inevitable operational challenges amid the ever-evolving regulatory environment. A core part of Ms. Banks' practice involves counseling clients around potential federal healthcare program overpayments. Her skill set includes analysis of conditions of payment, risk assessments, design and oversight of internal investigations of compliance and reimbursement matters, coordination of payment audits and, when needed, development of self-disclosure and voluntary refund strategies. Ms. Banks is deeply knowledgeable about Medicare and Medicaid reimbursement and funding mechanisms. She has extensive experience with payment requirements and policies under the various prospective payment systems and fee schedules, associated coverage policies and billing rules for various items and services, including such areas as nonphysician practitioner collaboration, Medicare cost-reporting considerations, hospital inpatient and outpatient billing requirements and beneficiary cost-sharing considerations. Ms. Banks' in-depth understanding of federal healthcare program design and payment streams makes her a strong strategist, issue spotter and problem solver when thinking through complex financial models and funding landscapes. In addition, Ms. Banks has experience advising and representing clients in government investigations and civil and criminal litigation involving allegations of fraud and abuse arising under the federal FCA and Stark Law, as well as the federal AKS and state law analogues. Ms. Banks has served as an adjunct faculty member at the University of Virginia School of Law

Ms. Waltz’ practice focuses on government investigations, false claims acts, corporate integrity agreements (CIAs), reimbursement strategies, bankruptcy, Medicare and Medicaid compliance counseling, and Medicare/Medicaid overpayments and enrollment disputes. She regularly advises clients who are the focus of government investigations and other enforcement actions and has negotiated false claims act settlements with the U.S. Department of Justice as well as CIAs with the Office of Inspector General. Ms. Waltz also provides ongoing compliance counseling and Medicare and Medicaid payment advice to clients, which include hospices, large physician practices, county health systems, hospitals, durable medical equipment suppliers, clinical laboratories, dialysis companies, skilled nursing facilities, ambulance companies, pharmacies, managed care providers, and a variety of other health care entities. She has also served as special Medicare counsel in the bankruptcy of San Diego Hospice, a large not-for-profit entity. Ms. Waltz has advised clients undergoing UPIC, ZPIC, RAC audits, other Medicare or Medicaid audits, overpayments, and pre-pay reviews. She is experienced in Medicare and Medi-Cal provider enrollment appeals and Medicare billing number revocations and other enforcement actions. Prior to joining the firm Ms. Waltz served as assistant regional counsel for the U.S. Department of HHS in San Francisco, primarily handling Medicare issues including survey and certification and various types of reimbursement disputes. She is Chair of the firm’s Health Care Practice Group and Co-Chair of the Health Care & Life Sciences Sector’s Providers of Health Care Services Area of Focus. She is also a member of the Government Enforcement Defense & Investigations and Bankruptcy & Business Reorganizations Practices.