Health Care Regulatory Counseling

Health care is one of the most highly scrutinized and regulated industries in the country. A vast array of ever-changing and highly technical laws and regulations govern the U.S. health care system. Failure to comply with these complex regulations can have staggering consequences for health care providers, including criminal liability, loss of licensure, exclusion from the Medicare and Medicaid programs, and severe financial penalties. Since 1997, more than $15.6 billion has been returned to the Medicare program through government efforts to crack down on health care fraud. With federal regulators recovering $17 for every $1 they invest fighting health care fraud and abuse, it is no wonder that this industry continues to be at the forefront of enforcement activities.

When the stakes are this high, you want the assurance of legal counsel with industry-specific knowledge and experience on your side. We have helped clients respond to regulatory investigations and audits at all stages of the process, from meeting with government officials early on in an investigation to understand and proactively address their concerns, to conducting full-scale compliance audits and reviews of business activities, to actively litigating complex cases. Our work in this regard includes assisting providers in defending against regulatory inquiries in a wide range of areas, including:

  • Enrollment, reimbursement, billing/coding, and participation requirements under the Medicare, Medicaid, and other federal and state health care programs
  • Health care fraud and abuse laws, such as federal and state Anti-kickback statutes and the federal Stark Law
  • Issues related to medical records confidentiality and HIPAA privacy and security compliance
  • Compliance matters associated with specific types of ancillary service providers, such as clinical laboratories, durable medical equipment suppliers, ambulatory surgery centers, and independent diagnostic testing facilities
  • Professional licensure matters
  • Federal False Claims Act and its qui tam whistleblower provisions

Gray Plant Mooty health care and litigation attorneys work hand in hand to leverage their deep expertise to assist providers with the most cost-effective and efficient defense possible. With a team that includes both former government prosecutors and senior health care regulatory attorneys who have been practicing for over 20 years, the health care team is well-positioned to aid providers in all stages of any regulatory inquiry or investigation.

Experience

Representative Matters

  • Represented home health care provider in responding to State Attorney General investigation involving criminal charges under the False Claims Act
     
  • Represented health care provider in responding to investigation by the U.S. Department of Justice in connection with qui tam action concerning Medicare billing issues
     
  • Represented individual physicians and health care professionals in licensing actions before the Minnesota Board of Medical Practice and other professional licensing boards
     
  • Conducted internal investigation on behalf of providers related to suspected fraud and abuse, upcoding, and various other billing irregularities
     
  • Developed and helped implement extensive compliance plan and training program for health care employees at all organizational levels on their duties, rights, and responsibilities should prosecutors come knocking
     
  • Represented provider of individual and small group health plans in an investigation by State Attorney General regarding provider’s payment of usual and customary rates for services provided by out-of-network physicians as well as provider’s compliance mandatory coverage and prompt payment requirements
     
  • Responded to licensing and accreditation challenges on behalf of individual providers before the Minnesota Boards of Medical Practice, Nursing, and Psychology
     
  • Represented health plans in actions related to state regulation, including an audit commenced by State Attorney General regarding compliance with laws regarding charitable and nonprofit entities; an action brought by a health plan against a service cooperative to prevent interference with the health plan’s marketing of health insurance to cooperative members; and reimbursement disputes involving both the usual, customary, and reasonable rates in workers’ compensation disputes as well as in matters relating to Medicaid coverage denials
     
  • Investigated compliance with Medicare and Medicaid billing, coding, enrollment, payment, and participation rules

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