Jim Gjerset is a founding partner of Gjerset & Lorenz, LLP.  Prior to entering private practice, Mr. Gjerset served as Assistant Attorney General with the Texas Office of the Attorney General, representing the state in provider fraud and abuse actions and unfair insurance fraud issues.  Mr. Gjerset continued his practice by joining the health care practice group of Haynes & Boone, LLP.  In 1998, Mr. Gjerset and Ms. Shauna Lorenz formed the now national health care law firm of Gjerset & Lorenz, LLP in Austin, Texas.

Mr. Gjerset has extensive experience representing a wide spectrum of the industry including institutional providers, individual providers, commercial payors, governmental payors, management services organizations and suppliers. Mr. Gjerset’s practice is presently focused on the provider side of the industry, and he routinely advises clients on complex governmental reimbursement issues, diverse business transactions, day-to-day operational issues, and regulatory compliance 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.  Mr. Gjerset also has extensive experience in the commercial insurance arena including negotiating managed care contracts for hospitals and physician groups.

Mr. Gjerset’s practice has recently emphasized developing innovative, regional Medicaid supplemental funding programs under Medicaid Upper Payment Limit (UPL) principles for hospitals in several states, in order to assist in obtaining additional entitlement funding for providers under Federal and State laws to alleviate the growing costs of treating low income and Medicaid patients.  In leading the development, design, and coordination of local collaborative efforts to create such programs, Mr. Gjerset has worked with participating hospitals and community leaders to analyze the benefits of these programs to their communities and thereby garner local support for the programs. 

Mr. Gjerset has also actively participated in broad-based Medicaid provider coalitions to analyze the financial implications of expanding Medicaid managed care and developed strategies to protect existing Medicaid financing mechanisms available to hospitals.  Further, Mr. Gjerset has provided analytical support to demonstrate the adverse implications of proposed changes to the Medicaid program on hospitals, and has developed and implemented programs to ensure state and federal agencies accurately include all services provided when calculating compensation related to the Medicare and Medicaid Disproportionate Share Hospital programs, as well as other Medicaid supplemental payment programs, for hospitals and hospital systems in numerous states including Alaska, California, Nevada, Arizona, New Mexico, Texas, Oklahoma, Missouri, Louisiana, Pennsylvania, Florida and the District of Columbia.  Mr. Gjerset also regularly assists hospitals to analyze the financial implications, regulatory issues and practical steps of a change in hospital operations, including consolidating hospitals under a single license and provider number, segregating previously combined campuses, or acquiring new facilities. 

Representative Experience

• Successfully appealed suit to Texas Supreme Court, against state Medicaid agency, related to the appropriate calculation of hospital Medicaid reimbursement rates;
• Successfully developed Medicaid supplemental payment program under Medicaid UPL principles that, in its first year of operation, generated more than $477 million in reimbursement for participating hospitals;
• Successfully defended a state recoupment effort alleging overpayment of an aggregate $30 million from over 25 providers due to the inclusion of alleged unallowable costs;
• Successfully defended over 100 license revocation, decertification and administrative penalty actions by state and federal regulatory agencies;
• 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 several states, including Texas, Idaho, New Mexico, and Florida;
• Developed policies, procedures and plans of action for the closure of numerous acute care hospitals, psychiatric hospitals, rehabilitation hospitals and ancillary services providers;
• Led the divestiture of a national home health division to numerous institutional and individual purchasers;
• Successfully recouped over $20 million in withheld Medicaid and tobacco pool funding for four psychiatric hospitals for whom the State argued had exceeded their hospital specific limits;
• Performed due diligence analysis for hospitals in several states to assess future viability and/or permissibility of current governmental reimbursement streams;
• Successfully defended individual owners from personal liability for over $5 million in governmental overpayments due upon cost report reconciliation;
• Assisted Texas hospitals to analyze, model, and assess the implications of the expansion of the Medicaid STAR+PLUS program, and to identify, educate and inform state leadership regarding the collateral impact on the Medicaid program;
• Successfully defended and appealed a $5.5 million recoupment action initiated against several Pennsylvania hospitals related to their receipt of funding under the Medicaid DSH program;
• Assisted in the successful development and implementation of legislation in Texas creating health care funding districts to generate local tax revenue eligible for federal supplemental payment programs;
• Developed regional Medicaid programs for public hospitals that generate over $15 million per year in federal matching dollars;
• Successfully defended a psychiatric hospital system from 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;
• Developed the strategy and led the negotiation and litigation teams in actions against various state and commercial payors nationwide resulting in:

• a $16 million global resolution of a dispute over the contractual provisions governing high cost pass through reimbursement;
• an injunction against a state Medicaid program for 14 public and private hospitals for failing to include a category of allowable costs that resulted in the underpayment of over $15 million per year for a four-year period;
• a $10 million settlement upon completion of the provider’s case in chief in a case where the insurer had denied hundreds of claims arguing that the hospital was required to bundle items and when the insurer had refused to pay for claims delegated to a defunct IPA;
• a $5.5 million final judgment against a large managed care company that underpaid hundreds of claims arguing the contract required daily level of care authorizations, refusal to comply with stop-loss provisions and down-coding;
• a $4.5 million arbitration award against a Medicare+Choice plan for excluding non-allowable Medicare items from the contractual reimbursement;
• a $4.3 million settlement of underpaid claims from a national insurer that argued its delegated IPAs were responsible for the claims;
• a $3.8 million judgment plus interest and penalties against an IPA that removed line item charges prior to calculating payment for stop-loss claims;
• a $3.1 million recovery against a state Medicaid program for inappropriate timely filing denials.

Professional Affiliations and Activities

• Past President of the Travis County Bar Association’s Health Law Section; Member: American Health Lawyers Association; Health Law and Administrative Law Sections of the State Bar of Texas; Administrative Law and Regulatory Practice Section of the American Bar Association; 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

Education and Professional Qualifications

• American University, Washington College of Law, J.D., cum laude, 1992
• Brown University, B. A., 1987
• Licensed to practice in Texas and the United States District Courts for the Northern, Southern and Western Districts of Texas

Speeches and Articles
Mr. Gjerset has spoken and written on a variety of matters, including Medicaid supplemental reimbursement and Medicaid UPL programs, corporate compliance programs, EMTALA, fraud and abuse, hospital licensing rules, Medicaid Disproportionate Share Hospital funding, charity care, discounting, silent PPOs, managed care contracting, confidentiality of medical records, and the duty to warn.  Speaking engagements include:

• Changing Landscapes: The Changing Medicaid Landscape – Healthcare Financial Management Association (Lone Star Chapter) – August 24, 2007
• Financing Medicaid Supplemental Payment Programs For Hospitals – American Health Lawyers Association – March 23, 2007
• The State of Healthcare – Health Financial Management Association (Texas Chapters’ Annual Conference) – March 26, 2007
• Medicaid DSH, UPL, and Other Supplemental Payments – American Health Lawyers Association – March 24, 2006
• Managed Care Disputes in Texas: A Retrospective, Concurrent and Prospective Approach to Pursuing Accounts Receivable – Managed Care Presentation at the October Health Law Meeting for the Dallas Bar Association – October 15, 2003
• HMO Managed Care Law: Health Care Arbitration in Texas – State Bar of Texas – November 7-8, 2002
• Medicaid Reimbursement – 2001: Medicaid DSH, Medicare DSH, Standard Dollar Amount, Upper Payment Limit and Outpatient Reimbursement: The Seven Deadly Sins of Reimbursement – Texas Association for Healthcare Financial Administration (TAHFA) – October 25, 2001
• Breaking a Leg (or Breaking Even)? Managed Care Reimbursement Myths and Reality – Texas Hospital Association Conference – November 2001
• Medicaid DSH- Reality v. Rhetoric: Compliance & Prospective Planning – 2nd Annual Update for Hospital District Legal Counsel – May 5, 2000
• The Politics of Managed Care – Texas Hospital Association Managed Care Conference, Maximizing Managed Care: Politics, Policy and Pricing – March 1, 2000
• Don’t Leave Money on the Table – Texas Hospital Association Managed Care Conference, Maximizing Managed Care: Politics, Policy and Pricing – March 2, 2000
• Taking Care of the Obligations and Opportunities that Arise from the Delivery of Indigent Care – the Association of Texas Hospitals and Health Care Organizations Annual Conference and Expo. – June 14, 1999
• Charity Care, Discounting and Silent PPOs – The Good, The Bad and the Ugly – Healthcare Financial Management Association Lone Star Chapter Membership Education Program – September 24, 1998
• Charity Care, Discounting and Silent PPOs – The Good, The Bad and the Ugly – Texas Conference of Catholic Health Facilities – September 3, 1998
• Hospital Charity Care Reporting Issues – The Texas Association for Healthcare Financial Administration Annual Meeting – April 26-28, 1998