Understanding the nuances of Medicare and Medicaid reimbursement is one of the greatest challenges that providers face in today’s quickly changing health care world. The reimbursement process can be long and arduous, and can change often, as described in this quote:

"There can be no doubt but that the statutes and provisions in question, involving the financing of Medicare and Medicaid, are among the most completely impenetrable texts within human experience. Indeed, one approaches them at the level of specificity herein demanded with dread, for not only are they dense reading of the most tortuous kind, but Congress also revisits the area frequently, generously cutting and pruning in the process and making any solid grasp of the matters addressed merely a passing phase."

— Rehab. Ass'n of Va. v. Kozlowski, 42 F.3d 1444, 1450 (4th Cir.1994).

Reimbursement is driving the current evolution of health care and the inability of some providers to understand or take advantage of these changes may threaten their very existence. Polsinelli boasts one of the largest health care reimbursement groups in the country with strong experience in all areas of reimbursement. From understanding byzantine coverage requirements to handling the most complex audits, our team regularly assists providers in making sense out of one of the most convoluted areas of health care. Our experience includes:

  • Assistance with responding to and appealing audits (e.g., Medicaid, Medicare, ZPIC, and RAC)
  • Strategic advice on clinical alignment, pay for quality and bundled payments
  • Assistance with analyzing and reporting overpayments
  • Counseling on Provider Based Billing
  • Counseling on DSH qualifications
  • PRRB Appeals
  • Prepayment Reviews
  • GME Reimbursement Compliance
  • Medicaid Managed Care and Dual Eligible Managed Care Programs
  • 340B Compliance
Our team includes the former Deputy Director of Colorado’s Medicaid agency, former OIG counsel, multiple former Assistant U.S. Attorneys with experience in health care fraud, former in-house counsel, a licensed CPA attorney who served as an in house accountant for a hospital and several former consultants. Our team is familiar with all of the various administrative appellate venues and regularly works with CMS to resolve complex reimbursement issues. We also have a strong Public Policy team that intimately understands health care reimbursement issues and works with our clients in pursuing legislative strategies to address their most pressing reimbursement needs.
Related Capabilities
340B Drug Pricing ProgramHealth CareReimbursement Audits & DisputesPublic Policy - Health Care
Publications
All Publications
House Panel Moves to Block CMS’s AI-Driven Prior Authorization Program: What the WISeR Rider Could Mean for Providers
Key Takeaways The House Appropriations Committee approved a rider June 9 that would block FY 2027 funding for CMS’s WISeR model. Unless the rider becomes law, however, the AI-driven prior authorization program will remain active in the six states where it currently operates. The rider could halt WISeR for FY 2027, but several legislative paths remain in play. Senate negotiations, a conference agreement or a continuing resolution could allow the program to continue, meaning providers should assume WISeR requirements remain in effect for now. Providers should continue documenting WISeR non-affirmations, appeals, outcomes and operational burdens. Those records may prove valuable for compliance efforts, litigation strategy and legislative advocacy as scrutiny of the program continues. On June 9, 2026, the House Appropriations Committee approved a
Read More
CMS Issues a Proposed Rule Impacting Quality Reporting, Care Compare and MDS Requirements for Skilled Nursing Facilities
Key Takeaways: CMS has proposed FY 2027 SNF PPS updates, including a 2.4% payment increase and changes to quality reporting and data submission. The proposal also removes certain COVID-19 measures and updates Care Compare reporting. The proposed changes would expand reporting obligations and accelerate submission timelines for skilled nursing facilities, potentially increasing administrative burden and compliance risk. Providers should assess the impact on operations and reporting processes and consider submitting comments before the June 1, 2026 deadline. The Centers for Medicare & Medicaid Services (CMS) has released a proposed rule updating the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) for FY 2027. The proposed rule signals CMS’ continued shift toward tighter reporting timelines, broader data collection and reduced reliance on pandemic-era quality measures
Read More