Government Reimbursement

Provider reimbursement is central to Gjerset & Lorenz’s practice. The firm is recognized nationally for its work in complex governmental reimbursement issues. Gjerset & Lorenz has extensive experience in navigating the regulatory framework for purposes of Medicaid, Medicare, CHAMPUS and Workers' Compensation reimbursement, handling hundreds of Medicaid and Medicare appeals representing over $300 million in reimbursement impact over the last two years alone.

Gjerset & Lorenz provides clients with a full range of services in connection with reimbursement from governmental payors, their related carriers and fiscal intermediaries. Payments for services from government programs have a significant financial impact on healthcare providers and we work closely with our clients’ operations, finance, legal and reimbursement departments to assure that our clients are fully apprised of the reimbursement implications of business strategies and alternative options for achieving similar operational results without sacrificing reimbursement. Of paramount importance to Gjerset & Lorenz lawyers is to ensure our clients understand the activities necessary to adhere to all applicable governmental regulations and receive the full amount of reimbursement to which they are entitled.

In this area of the law, our attorneys strive constantly to stay one step ahead of the changing legal and regulatory landscape. We work closely with our clients to maneuver through complex reimbursement issues and counterintuitive reimbursement structures that are so prevalent in government program reimbursement today.

Gjerset & Lorenz’s legal services related to government program reimbursement includes:

• Working with hospitals and hospital systems in numerous states including Alaska, California, Nevada, New Mexico, Texas, Missouri, Louisiana, Pennsylvania, Florida and the District of Columbia to develop and implement systems to facilitate accurate reporting of qualification and compensation data and to ensure state and federal agencies accurately include all services provided when calculating compensation related to Medicaid Disproportionate Share Hospital funding and Upper Payment Limit funding.
• Developing Upper Payment Limit (UPL) programs using local tax dollars to generate millions of dollars each year in new federal matching dollars for individual hospital clients who provide significant services to the uninsured and low-income populations.
• Working with our clients’ government relations divisions and lobbyists to develop new reimbursement models for state government program funding.
• Working with various state hospital associations to develop mechanisms to appropriately draw the maximum federal matching funds.
• Due diligence analysis of the government program reimbursement impact of realigning multiple hospitals within the same markets.
• Advising providers on governmental conditions of participation, billing and coding requirements, coverage issues, provider-based status and Federally Qualified Health Centers implementation, and fraud and abuse matters.
• Working with providers to develop responses to state and federal Medicare and Medicaid audit findings and representing providers facing governmental investigations of their billing practices.
• Performing Medicare and Medicaid cost report analysis and preparing, filing and appealing requests for re-openings and Medicare Part A Reimbursement Appeals.

When administrative processes fail to provide our clients satisfactory results, Gjerset & Lorenz has successfully litigated Medicaid and Medicare issues in administrative forums and courts.