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Stephen M. Elwell
Stephen Elwell is a partner with Gjerset & Lorenz, LLP, where he focuses on assisting institutional healthcare providers, including hospitals, nursing homes, residential treatment facilities, and freestanding psychiatric hospitals, related to their operations and their participation in private and governmental reimbursement programs. He began his work at Gjerset & Lorenz as a summer associate and law clerk in 2003 before joining the firm as an associate in 2005.
In Mr. Elwell’s practice, he has:
- Represented providers, working with State Medicaid agencies, in all aspects of the design, development, and implementation of programs intended to increase reimbursement to help offset the gap between cost and existing payments. This work included identifying applicable federal and state reimbursement limits, designing program structures based on these limits, evaluating and modeling opportunities for providers to receive additional funding and any offsetting impact, designing program payment vehicles, and coordinating financing payments under:
- the Medicaid Disproportionate Share Hospital program;
- the Medicaid fee-for-service (Upper Payment Limit) program; and
- the Medicaid managed care program (including Directed Payment Programs under 42 C.F.R. § 438.6).
- Represented providers in the continuation and operation of these programs, including ongoing analysis of applicable legal issues, maintenance of operative agreements and corporate entities, financial forecasting and budgeting, strategic analysis of proactive strategies to modify program participation, and coordination/communication with public and private partners.
- Structured, developed, and assisted hospitals, working with Medicaid managed care organizations and State Medicaid agencies, to implement and operate programs to incentivize delivery system reforms and quality-driven improvement of health and outcomes for the Medicaid fee-for-service and Medicaid managed care populations based on projects designed in accordance with the State’s Quality Strategy. This work included designing the program and assisting in the development of the underlying quality initiatives, coordinating a diverse group of provider and MCO stakeholders, assisting the State to obtain federal approval, and coordinating operation of provider networks and reporting of achievement.
- Advised hospitals in many states related to their participation in the Medicaid Disproportionate Share Hospital program, including qualification analysis, hospital compliance reporting, administrative appeals of agency determinations, participation in federally-mandated audits, and projections of future revenues.
- Represented numerous physician and mid-level practitioner groups in all aspects of their participation in Medicaid Upper Payment Limit programs and Medicaid fee-for-service and managed care reimbursement.
- Drafted and negotiated hundreds of agreements between hospitals, physicians, and other healthcare organizations and professionals.
- Structured and restructured hospital and physician relationships to ensure their consistency with state and federal prohibitions on the payment of consideration to induce physician referrals (Stark and Anti-Kickback laws).
- Assisted in the due diligence analysis for hospital acquisitions related to the viability of current Medicaid revenue streams and the identification of opportunities for additional sources of revenue after acquisition.
- Helped freestanding psychiatric hospitals and residential treatment facilities in several states to develop and propose Medicaid reimbursement methodologies that more appropriately reimburse the unique costs borne by these facilities.
- Drafted lease agreements, management agreements, option agreements, promissory notes and security agreements related to the transfer of ownership interests and/or operational responsibilities for hospitals.
- Advised hospitals and non-hospital providers regarding the implications of state and local government obligations on the services offered by private providers, including the implications of sovereign immunity, federal grant obligations, state budgetary restrictions and requirements under governmental services programs.
- Assisted hospitals to form non-profit corporate entities, maintain these entities in compliance with applicable law, and secure appropriate licensure for these entities’ provision of healthcare services.
- Assisted hospitals in the development and redesign of charity care and bad debt policies in order to more accurately reflect hospital operations while maintaining consistency with state and federal limitations.
- Advised hospitals and worked with State Medicaid agencies related to the application of budget neutrality-based caps on reimbursement under programs authorized pursuant to an 1115 Waiver.
- Advised hospitals and worked with State Medicaid agencies related to actuarial soundness limits on capitation payments to Medicaid managed care organizations.
- Advised hospitals related to their participation in state and local indigent care programs.
- Represented hospitals in arbitration and litigation for the recovery of systemic underpayments from managed care organizations.
- University of Texas School of Law, J.D., 2005
- University of Texas, B.B.A. in Management Information Systems, Minor in Finance, 2002
- Past Secretary, Member, Austin Health Lawyers Association
- Member, American Health Lawyers Association
- Member, American Bar Association