Health Care Regulatory & Compliance

Medicare fraud enforcement efforts are steadily increasing, with civil and criminal fraud recoveries exceeding $2 billion annually and increasing numbers of whistleblower lawsuits. With the introduction of tighter regulations and better technology that can spot data anomalies, health care providers must be more vigilant than ever in ensuring they are complying with increasingly complex regulations.

Key Contacts

Anthony R. Miles Partner Seattle, WA
Kelly Knivila Partner Portland, OR
Barbara L. Nay Partner Portland, OR
See all contacts
Overview

Health care entities—whether nonprofit or for-profit—are subject to significant and rapidly evolving state and federal regulatory requirements. Our team’s focus is on ensuring your organization is compliant with current regulatory requirements, is equipped to maintain compliance, has adequate policies and processes in place to address the regulations, and is vigorously represented and defended if compliance is called into question. We accomplish this through audits, training, analysis, informal and formal agency outreach, representation before administrative agencies, effective settlement negotiations and aggressive defense in and out of court.

Our Services

  • Provider and Payer Contracting
  • Stark Law
  • Fraud and Abuse
  • Audits, Investigations and Appeals
  • Antitrust
  • Medicare and Medicaid
  • Government Reimbursement
  • Insurance Regulation
  • Self-Disclosure Counseling
  • False Claims Act/Qui Tam
  • Pharmacy Regulation

In addition to focusing on keeping your day-to-day operations compliant, we help with regulatory issues involved with planning and structuring transactions. This is particularly important with regard to antitrust and fraud and abuse compliance. Our regulatory compliance and corporate transactions attorneys work hand in hand to ensure all necessary analysis and regulatory due diligence are completed so your transaction keeps moving to close.

Matters

Regulatory & Compliance

  • Represented a physician practice in connection with analysis of Stark violations arising under the group practice/in-office ancillary services exception, and undertaking a self-disclosure.
  • Represented Medicaid Dental Care Organization in responding to Oregon Department of Human Services' audit of contract compliance and negotiated favorable compliance plan resolution.
  • Represented a rural hospital in seven appeals before the Provider Reimbursement Review Board. Successfully negotiated return of all funds totaling almost $3 million that had been recouped by the hospital's fiscal intermediary.
  • Represented a large, multi-state practice management company in a successful negotiation with the U.S. Department of Human Services' Office of Inspector General of a corporate integrity agreement resolving False Claims Act allegations.
  • Provided chief outside privacy counsel for a technology and business process outsourcing contractor balancing information security requirements under federal Privacy Act, Department of Defense and agency rules, and federal and state rules governing identifiable health information, genetic information and security breach issues.
  • Represented physician network organization in successfully obtaining certificate of authority as a health care service contractor.
  • Represented a retail pharmacy chain in self-disclosing to Oregon Department of Human Services errors in Medicaid reimbursement requests and negotiated favorable resolution. 

Fraud & Abuse

  • Represented a hospital that was raided by federal agents armed with subpoenas issued as a result of a qui tam action. Ultimately the United States declined to intervene, and the case was settled with the relator on favorable terms.
  • Represented a nephrology clinic in a case brought by a former employee (a nephrologist) alleging that the clinic systematically overbilled Medicare for treatment of hospitalized dialysis patients. The case was settled after mediation.
  • Represented 12 Oregon hospitals under investigation for alleged civil fraud in connection with outpatient laboratory billings.
  • Represented a provider against U.S. Department of Justice allegations that the provider upcoded claims in violation of the False Claims Act. The case was settled for less than the government’s initial single damages claim.
  • Represented a large, multi-state practice management company in successful negotiation with the U.S. Department of Human Services’ Office of Inspector General of a corporate integrity agreement resolving False Claims Act allegations.

Government Reimbursement

  • Represented an owner and operator of adult foster and residential treatment homes in the settlement of a Medicaid audit with the Oregon Department of Human Services (DHS). After DHS proposed to recoup over $900,000 in payments, we negotiated a settlement to reduce its payment recovery to $31,000.
  • Represented a federally qualified health center in responding to a state audit of its Medicaid billings, including negotiating a reduced overpayment obligation for the audit period that was less than half the original amount.
  • Represented a rural hospital in seven appeals before the Provider Reimbursement Review Board. Successfully negotiated return of funds totaling almost $3 million that had been recouped by the hospital’s fiscal intermediary.
  • Represented a mental health provider in responding to the state’s audit of its Medicaid billings; the provider’s overpayment obligation was reduced by more than half.
  • Assisted various physician groups and other providers in investigating and assessing Medicaid and Medicare overpayments and negotiating repayment obligations with the responsible government agencies, frequently for significantly less than the client’s initial calculation.
  • Represented a hospital with respect to Medicaid managed care plan subcontractor’s recoupment of almost $300,000 from claims previously paid. Successfully negotiated resolution of claims resulting in return to hospital of 95% of recoupment amount.

Antitrust

  • Defended a health care network in an antitrust challenge by ancillary service providers; the challenge arose out of the network’s refusal to include the providers on its panel.
  • Assisted with the formation of a network of cardiovascular surgeons and represented the network in connection with a state antitrust inquiry into the legality of the network.
  • Assisted with the formation of a physician hospital organization and related antitrust advice.
  • Ongoing counsel to an independent practice association concerning antitrust compliance.
  • Ongoing representation of a state dental association in connection with antitrust compliance.
  • Represented a physician-controlled health care service contractor and provided advice on antitrust compliance.
Team
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