In recent years, the health care industry has experienced dramatic change, extraordinary competition, and an increasingly complex legal and regulatory environment. Michael G. Apolskis, P.C. has experience assisting health care providers, suppliers and companies in addressing such challenges and achieving their strategic and operational objectives. To that end, the firm provides advice, guidance and services in areas such as:
Regulatory Compliance. The firm provides advice, guidance and services covering nearly every aspect of federal and state health care regulation, including:
- Licensure, certification, enrollment and accreditation
- Medicare conditions of participation
- Medicare staff by-laws, credentialing and peer review
- Changes of ownership and successor liability
- Billing, charges, coding and cost reporting
- Medical necessity, coverage decisions and claim submissions
- Discounts, rebates and beneficiary inducements
- Advance beneficiary and discharge appeal notices
- Fee splitting, reassignments and gainsharing
- Hospital acquired conditions/present on admission indicator issues
- "Incident to" physician services
- Under arrangements and provider-based status
- Surveys, citations, violations and corrective action plans
- Quality of care and utilization reviews
- Emergency Medical Treatment and Active Labor Act (EMTALA)
- Documentation practices and procedures
- National Practitioner Data Bank
- HIPAA and state law privacy and security
Corporate & Business Transactions. The firm provides advice, guidance and services addressing the regulatory issues that arise in corporate and business transactions, such as:
- Mergers, acquisitions and consolidations
- Joint ventures, affiliations and strategic alliances
- Reorganizations, liquidations and dissolutions
- Outsourcing and other contractual arrangements
Fraud & Abuse. The firm provides advice on the structure of transactions, arrangements and practices to minimize possible fraud and abuse implications and liability arising from:
- Federal false claims act
- Federal anti-kickback statute
- Stark self-referral statute
- State fraud and abuse laws
- State whistleblower laws
Third Party Payment Guidance. The firm counsels health care providers, suppliers and companies on the regulatory intricacies of Medicare, Medicaid and other third party payment, including:
- Reasonable cost reimbursement
- Hospital inpatient and outpatient prospective payment systems (PPS)
- Physician resource-based relative value scale (RBRVS)
- Skilled nursing facility PPS
- Home health PPS
- PPS exempt units and facilities
- Disproportionate share hospital (DSH) adjustments
- Graduate medical education (GME) payments
- Bad debt payments
- Cost outlier adjustments
- New technology payments
- Competitive acquisition programs
- Medicare & Medicaid managed care
- Medicare prescription drug benefits
Third Party Payment Disputes. The firm represents health care providers and suppliers in third party payment disputes, controversies and administrative proceedings involving:
- Medicare intermediaries and carriers
- Medicare administrative contractors (MAC)
- Durable medical equipment regional carriers (DMERC)
- Regional home health intermediaries (RHHI)
- Qualified independent contractors (QIC)
- Recovery audit contractors (RAC)
- Provider reimbursement review board (PRRB)
- Administrative law judges (ALJ)
- Departmental Appeals Board (DAB)
- State Medicaid agencies
Audits & Investigations. The firm provides advice, guidance and representation in Medicare, Medicaid and other third party payment audits and investigations involving:
- Billing, charges, coding and cost reporting
- Medical necessity, coverage decisions and claim submissions
- Surveys, citations and corrective action plans
- False and fraudulent claim assertions
- Coordination of benefits and Medicare secondary payer rules
- Reopenings, recoupments and suspension of payments
- Debarments and program exclusions
- Suspension and revocation of professional licenses
- Assessment of civil monetary penalties
- Voluntary refunds, disclosures and OIG's self-disclosure protocol
- Corporate integrity agreements
- Search warrants, subpoenas and civil investigative demands
Enforcement. The firm provides advice, guidance and representation in enforcement matters involving federal, state and local government agencies, including:
- U.S. Department of Health and Human Services (HHS)
- HHS' Office of Inspector General (OIG)
- Centers for Medicare & Medicaid Services (CMS)
- U.S. Department of Justice
- Federal Bureau of Investigation
- U.S. Attorney General
- State Attorneys General
- Medicaid Fraud Control Units
- State Medicaid agencies
- State departments of public health
- State departments of professional regulation