The planning, delivery of and payment for modern health care services are among the most complex and resource intensive endeavors in the world. Recognition of this fact is the driving force behind the development of our health care practice. This cornerstone practice for Stewart Strong has been created by professionals who have represented health care facilities, providers and related businesses for decades in both in house and outside counsel capacities. Having stood in the shoes of both attorney and client, our health law team regularly delivers practical advice in several key areas of this discipline.
Whistleblower cases under the federal False Claims Act and similar state statutes carry the threat of substantial monetary damages and penalties for Defendants, but the exclusion from federal and state programs Defendants can face can be even more devastating to them. Nowhere is this more true than in the health care field. Stewart Strong can bring the full depth and breadth of its years of experience in representing health care providers to bear to protect the interests of its clients sued in qui tam cases. We actively seek early opportunities for negotiated resolution before the government’s deadline to intervene expires, but if a better result for the client can only be achieved through litigation, our team is aggressive in seeking to have those cases dismissed once unsealed and, should trial ultimately be in the client’s best interest, to trying the cases to verdict.
As health care costs continue to rise, the efforts of both government and private health care payers to combat fraud and abuse in the provision of and reimbursement for health care goods and services have escalated exponentially. As a result, business practices and arrangements that are routine in many other industries have become subject to a health care regulatory structure that is as unique as it is challenging. Hospitals, physicians, laboratories, pharmacies and many other health care clients regularly turn to us to help them strike the difficult balance of good business and regulatory compliance.
The attorneys in our fraud and abuse practice have extensive experience with matters involving the federal Stark Law and Anti-Kickback Statute as well as similar state laws and regulations. We combine deep knowledge in these and other key areas with front line experience as in-house attorneys and compliance advisors. The result is an approach to fraud and abuse law compliance that is driven by practical solutions and preventative strategies.
We audit existing contracts and financial relationships and conduct prospective reviews of the regulatory implications of new relationships and business ventures. Clients often involve our team early in the creation of leases, services contracts and employment arrangements which are subject to fraud and abuse laws. We also help clients minimize potential fraud and abuse liability by developing compliance plans and policies and procedures for contract development and billing/collection activities. When suspected violations are identified we assist with strategic plans to correct problematic arrangements and evaluate options for self-disclosure to various governmental authorities. While seeking to resolve such matters with governmental entities through cooperation and negotiation, if litigation ensues, we draw on the civil and criminal experience of our seasoned litigation team, who are prepared to bring their trial skills, honed through years in the courtroom, to bear when needed. We also have the experience to assist clients who are requested to enter into corporate integrity agreements to resolve matters and clients who must function within the special requirements of corporate integrity agreements into which they have previously entered.
The rules aimed at combating fraud and abuse continue to evolve as new laws are passed, new regulations are promulgated, new cases are tested in the courts, and new government settlements take place. All of these developments require ongoing reviews of new and existing contractual and financial relationships and business practices. Our health care attorneys focus their practices in this area and are here to help.
The legal questions that arise from the day to day operation of the structures that deliver health care are constant, ever-changing and highly complex. Our legal team answers and anticipates these questions on a daily basis for the smallest outpatient clinics as well as some of the largest metropolitan medical centers with hundreds of beds and thousands of employees.
In their roles as operations counsel, our attorneys address a broad array of issues to help keep facilities running. We help new and expanding facilities with the often difficult process of licensure and certification. We assist business representatives as they contract for necessary equipment, supplies and services. We work with nursing and medical staff leadership to develop sound clinical policies and procedures. We are also frequently consulted to assist health information management professionals when questions arise related to privacy and security of patients’ health information. The scope of our advice also extends to other areas including Medicare Conditions of Participation, Joint Commission accreditation standards, state health department regulations and many other requirements that are imposed upon health care providers and institutions.
Health care providers and institutions face unique challenges not seen in other industries when it comes to obtaining compensation for the goods and services they provide. Reimbursement in the health care arena is significantly affected by the prevalence of third party payment, complexity of many payment arrangements, a highly restrictive regulatory structure, and a variety of other factors.
Our lawyers understand the many challenges of health care reimbursement and regularly counsel health care providers and institutions in this area. We are often consulted regarding issues related to managed care contracting and federal health care program enrollment. We assist our clients with managing overpayments and the related potential for recoupment actions as well as the difficulties often associated with payments to out-of-network providers. Additionally, we guide clients through a host of other billing and collection related matters and help them to establish efficient and compliant billing policies and procedures.
Along with a great deal of prospective reimbursement advice, we also provide representation if clients are denied payment for health care services by both private and government payers. When this occurs, and unfortunately it often does, we assist with advocacy throughout the often complex administrative appeal processes which most payers mandate. If these processes are unsuccessful, we can and do pursue legal action against payers who refuse to comply with their contractual obligations to make payment for legitimately performed health care services. In some cases, we have pursued and successfully collected on claims that our clients felt were unlikely to be paid.
The unique legal and business relationship between hospitals and their staffs of independent health care practitioners is one of the most complicated aspects of health care delivery. Effective management of this relationship demands counsel with the knowledge base and experience to correctly identify, analyze and respond a variety of legal, business and political considerations.
We have drafted medical staff bylaws, medical staff rules and regulations, and have prosecuted, defended and served as hearing officers in a variety of medical staff proceedings. We regularly advise hospitals, medical staff leadership and medical staff committees with respect to specific problems. We are also often called upon prospectively to help develop effective processes that minimize risk in this complex area.
Our talented team brings a combination of deep understanding of the relevant statutes, regulations and case law, extensive work before state licensing agencies and considerable health care litigation experience. This combination allows us to truly understand our clients’ medical staff problems and help to solve them — quickly.
We understand the importance of securing and maintaining the licensure credentials required for health care professionals to practice and we are regularly called upon to assist in this process. We interact with and appear before state authorities that license physicians, nurses, pharmacists, psychologists and other professionals and have considerable experience with many of these bodies and how they operate.
Our attorneys have assisted with the often complicated licensure applications of professionals who are foreign nationals as well as those who have criminal records. Additionally, we are familiar with the aggressive positions taken by some state licensing bodies when investigating patient complaints and we have successfully responded to and resolved many complaint investigations.
Professionals also seek our counsel when they are accused of violating the various laws and regulations that govern the terms of their respective licenses. In these instances, we have experience with negotiating agreed sanctions in lieu of enforcement actions. If necessary, we also have the knowledge and experience to appear at formal administrative hearings to defend our clients’ licenses.
When licensure action negotiations and/or proceedings are concluded, regardless of the outcome we help our clients to continue practicing legally whenever possible. Professionals who resolve an issue with a licensing body are often subject to ongoing education and work supervision requirements. We assist these professionals with interpreting and complying with the terms of any ongoing requirements.
In the past, most physicians practiced alone or in small groups; they treated patients and were paid for their services. That simplicity is gone. Today, physicians practice in diverse settings, engage in a variety of different business relationships, and are subject to an imposing regulatory framework.
Legal services for physicians are difficult to provide without a deep understanding of this new landscape. Our professionals have developed this understanding from our work as in-house attorneys and consultants for a variety of physician organizations.
Using our in-house knowledge and perspective, we provide exceptional counsel that allows physicians to comply with legal requirements and effectively manage business relationships.