Nelson Hardiman is a recognized leader in advising and defending Medicare providers in California. For an industry focused on regulatory compliance, we tackle the full range of Medicare-related issues head-on. As Medicare increasingly seeks to contain the rising costs of healthcare in the face of a federal crackdown on Medicare abuse, we help healthcare providers justify the medical necessity of the services they provide and protect physicians from accusations of overpayment and fraud.
Our team of Medicare lawyers develop compliance programs, provide audit assessments, and defend providers who experience problems with their participation in the Medicare program. From enrollment issues to recovery audits, we resolve complex Medicare issues and counsel on Medicare compliance, including Medicare Secondary Payor (MSP) issues. We defend healthcare providers in Medicare Part B recovery audits and appeals. We defend providers from claims by private health plans and payor auditors who pursue reimbursement refunds based on patient Medicare coverage. Whatever the Medicare challenge, Nelson Hardiman has the legal knowledge and experience to navigate the complex landscape of regulatory compliance on behalf of healthcare providers.
Our Work Includes:
- Audit Appealed a Medicare audit that had been “lost” in the system, depriving the provider of the opportunity to contest overpayment findings. We sued the contractor and CMS to compel the reinstatement of the appeal and successfully defend the provider before the Office of Medicare Hearing Appeals (OMHA).
- Fraud and Abuse Persuaded Medicare to abandon a $800,000 overpayment demand against a physician based on his disclosure of fraud and abuse by a clinic manager.
- Medicare Advantage Ran a Medicare Advantage program for a hospital and negotiated new contracts with Medicare Advantage plans on behalf of an IPA.
- Office of Medicare Hearing Appeals (OMHA) Represented a multi-office medical group for alleged overpayment of $5.6 million in diagnostic testing, office visits, and other services. Appeal to OMHA reduced the overpayment to $80,000, a reduction of over 98.6%.
- Provider Underpayment Represented a hospital in litigation and settled with a national Medicare supplement insurer and its associated endorsing agent over underpaid provider claims.
- Reimbursement Represented a physician who provided intravenous immunoglobulin (IVIG), a treatment for autoimmune diseases. When the contractor contended that the patients failed to meet the Medicare-established criteria for IVIG, we demonstrated medical necessity resulted in overturning of all but $300 of the $1.4 million claim.