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James E. Gjerset
Mr. Gjerset founded Gjerset & Lorenz, LLP in 1998 with Shauna Lorenz. Mr. Gjerset has extensive experience representing a wide spectrum of the healthcare industry, and he routinely advises clients on complex government reimbursement issues, diverse business transactions, day-to-day operational issues, and regulatory compliance. Mr. Gjerset works with healthcare providers on a broad swath of issues including licensure, certification, reimbursement, antitrust, fraud and abuse, cost reporting, government contract negotiation, and preparing for, responding to, and defending against state and federal government investigations and administrative penalty actions. Prior to the creation of Gjerset & Lorenz, Mr. Gjerset served as an Assistant Attorney General in the Texas Office of the Attorney General focusing on healthcare, insurance and anti-trust regulations and was a member of the healthcare practice section of Haynes & Boone, LLP.
In the Reimbursement area, Jim:
- Designs innovative Medicaid supplemental funding programs for institutional providers across the country.
- Builds consensus between participating hospitals, community leaders, State and local governmental entities, and State Medicaid agencies.
- Designs coalitions to achieve the participants’ business goals while maintaining compliance with the complex set of applicable laws.
- Assists clients in obtaining approval of new Medicaid financing and governmental payment programs from the Centers for Medicare and Medicaid Services, implementing the programs and continuing to operate the programs to support on-going compliance.
- Develops strategies to protect existing Medicaid financing sources and payment streams.
- Provides analysis of the adverse and often unexpected implications hospitals would face under proposed reimbursement changes to their state Medicaid programs.
- Participates in broad-based Medicaid provider coalitions in several states to analyze the financial implications of Medicaid reform initiatives, including Medicaid managed care expansions, the implementation of Medicaid Waiver programs, and the adoption of provider taxes or assessments.
- Implements programs to ensure state and federal agencies accurately calculate compensation for services under the Medicare and Medicaid Disproportionate Share Hospital programs and other governmental payment programs.
- Assists hospitals to analyze the financial implications, regulatory issues, and practical steps involved in changing hospital operations, including consolidating hospitals under a single license and provider number, separating previously-combined campuses, acquiring new facilities, and changes of ownership.
- Designed innovative Medicaid supplemental payment programs that generate almost $2 billion in reimbursement for participating hospitals per year.
- Represented four psychiatric hospitals in a dispute over withheld Medicaid and tobacco pool funding when the State argued they had exceeded their hospital-specific entitlements.
In the Operations and Compliance area, Jim:
- Performed due diligence analysis for hospitals in several states to assess the viability and/or permissibility of current and proposed governmental reimbursement streams;
- Conducts compliance audits to review and restructure physician arrangements to comply with state and federal referral and kickback prohibitions for hospital system;
- Developed policies, procedures and plans of action for the closure, consolidation, or segregation of numerous acute care hospitals, psychiatric hospitals, rehabilitation hospitals and ancillary services providers; and
- Led the divestiture of a national home health division to numerous institutional and individual purchasers.
In the Legislative and Regulatory area, Jim:
- Assessed the viability and impact on hospital funding of legislative and industry proposals for Medicaid reform, including the impact of the expansion of Medicaid managed care delivery systems and Medicaid waiver programs in numerous states;
- Assisted in the successful development and implementation of legislation creating healthcare funding districts to generate local tax revenue eligible for federal supplemental payment programs; and
- Educate elected officials and agency staff and developed educational materials for client government relations teams regarding the collateral impact of these proposals.
In the Administrative Litigation area, Jim:
- Successfully coordinated the joint defense of a state recoupment effort alleging overpayment of an aggregate $30 million from 25 providers over the calculation of allowable costs for grant funding;
- Successfully defended behavioral health and substance abuse providers in over 100 license revocation, decertification and administrative penalty actions by state and federal regulatory agencies;
- Appealed a $5.5 million recoupment action initiated against several hospitals related to their receipt of funding under the Medicaid Disproportionate Share Hospital program;
- Counseled individual owners in a personal liability action for over $5 million in governmental overpayments due upon cost report reconciliation;
- Helped a psychiatric hospital system avoid exclusion of five of its hospitals from the Medicare and Medicaid programs, licensure revocation and civil penalties following several suicides and abuse and neglect findings; and
- Served as counsel in a lawsuit regarding the state counting additional costs in calculating the reimbursed rate for eight hospitals, resulting in two Supreme Court decisions.
- American University, Washington College of Law, J.D., cum laude, 1992
- Brown University, B.A., 1987
Professional or Trade Affiliations
- Past President of the Travis County Bar Association’s Health Law Section
- Member of the American Health Lawyers Association
- Member of the Health Law and Administrative Law Sections of the State Bar of Texas
- Member of the Administrative Law and Regulatory Practice Section of the American Bar Association
- Member of the Texas Hospital Association
- Past Vice-Chair of the Texas Department of Insurance Advisory Committee on unfair insurance practices
- Past Chairman of the Brackenridge Hospital Oversight Council
- Past Special Technical Advisor to the Texas Hospital Association’s Medicaid Tax Force