J. Everett Wilson

With a wide breadth of experience in the health care sector, J. Everett Wilson focuses his practice on assisting clients meet the challenges of a complex and highly regulated industry.  A true “regulatory” attorney with a business background, Everett represents health care providers and other health care and health care insurance entities on issues related to Medicare and Medicaid, operations, managed care, and the regulatory and business issues specific to health care M&A.

He utilizes his comprehensive understanding of the health care industry to provide strategic counsel on a full spectrum of health care legal and business issues and projects.  In that role, Everett regularly assists clients in the implementation of their strategic vision, whether by way of growth, implementation of newer business models and/or “best practices”, expansion of business lines, and/or ultimate sale.  Of particular note, is his extensive experience in the Medicare Advantage and Medicaid managed care arena, with a particular emphasis on full-risk arrangements and the regulatory and business issues related to the same.     

He often advises clients that operate in the intersection between payors and providers and the more recent trend towards the integration of those sectors.  In that respect, he is experienced in the establishment of provider based managed care companies, discount plans, pre-paid plans, TPA’s, provider networks and MSOs.  Further, while he advises established health care clients, he also advises health care entrepreneurs, private equity, and other investors relative to their foray into particular sectors of the health care industry and, in particular, the Florida market place. 

Over almost 30 years of practice, Everett has successfully represented many health care professionals, providers, and insurers at both federal and state level on numerous matters, including:

• Licensing and Changes of Ownership
• Disciplinary and Enforcement proceedings
• Medicare and Medicaid Provider Issues, including payment suspensions, pre-payment reviews, revocations, and enrollment
• Medicare and Medicaid Audits and Appeals
• Reimbursement and Overpayment Appeals
• Medicare MRA Audits
• Regulatory and Compliance Matters (including Fraud and Abuse)
• Provider Operations
• Medicare Advantage and Medicaid Managed Care
• Managed Care Contracting
• Non-Compete Agreements
• Health Care Joint Ventures
• Health Insurer Liquidations and Receiverships

Everett has additional experience on the transactional side, assisting clients in the purchase or sale of a wide variety of health care entities and actively represents both buyers and sellers in middle market transactions.

Selected Notable Cases

Stringer v. Fireman’s Fund Insurance Company, 622 So.2d 145 (Fla. 3rd DCA 1993): Represented client in a case of first impression that established Florida law for denial of insurance coverage based upon an insured’s failure to submit to a requested examination under oath (EUO)

In Re: RR Medical: Represented a client in a case of first impression that established evidentiary “without fault” standard in federal Medicare overpayment cases based upon “compliance with industry standards” and lack of actual knowledge

Board of Medicine Rule Challenge (2009): Represented a client in a case that found the medical expert witness disciplinary statute unconstitutional on due process grounds and unenforceable, thereby resulting in dismissal of Board of Medicine complaint premised on violation of statute at issue

AHCA Rule Challenge (2013): Represented a client in a case that found the Florida Agency for Health care Administration’s use of certain statistical methodologies to determine Medicaid overpayments unauthorized as a matter law, thereby invalidating the basis for in excess of 400 other pending overpayment cases

Representative Matters

Medicare Overpayment Appeals: Represented a national medical equipment provider in the appeal of a statistically estimated multi-million dollar Medicare overpayment and achieved a 99% reduction of the overpayment

Medicaid Overpayment Appeals: Represented a home health provider in the appeal of a Medicaid overpayment and achieved a full reversal of the contested portion of the overpayment

Medicare Provider Revocation: Represented a physician accused of overbilling in Medicare revocation proceedings and achieved a judicial finding that Medicare had no basis for the revocation, which resulted in the retroactive reinstatement of the client’s Medicare billing privileges, and the refund of monies paid in connection with the overpayment based on said overbilling

Medicare Payment Suspension: Represented a large medical equipment provider placed on payment suspension and obtained a withdrawal of the suspension within ten days

Medicare Pre-Payment Review Modification: Represented a large multi-office physician group (20 plus physicians) placed on Medicare pre-payment review and obtained removal from review within 30 days

Board of Medicine Disciplinary Proceedings: Represented a physician that had been the subject of national media coverage regarding prescribing practices and obtained a dismissal of the case based on conflicting expert testimony

Board of Dentistry Disciplinary Proceedings: Represented a dentist whose license had been previously revoked due to a federal criminal conviction, in obtaining a reinstatement of licensure

AHCA License Revocation/Non-Renewal: Represented a large Assisted Living Facility (ALF) faced with revocation and license non-renewal, and successfully contested allegations of historical non-compliance and avoided revocation and non-renewal

AHCA Disqualifying Offense Exemption: Represented a health care executive subject to ownership and management disqualification due to a youthful indiscretion, and obtained a permanent exemption on his behalf

License Transfers: Represented client in obtaining licensure and/or Medicaid change of ownership authorizations (CHOWS) in 48 states in connection with the sale of a national medical provider/wholesaler, which sale was conditioned upon obtaining said license transfers on an expedited basis

HIPAA Breach: Represented a large healthcare provider faced with a HIPAA security breach and advised client so as to achieve full compliance, remediation, and limitation of any potential penalties

Whistleblower/Qui-tam Defense: Represented a clinical laboratory faced with a federal qui-tam action and obtained a dismissal with prejudice of the case

Health Care Employment Disputes: Represented numerous practices and physicians with either enforcement or avoidance of contractual non-compete provisions

Health Care Related Overtime Claims: Represented home health agency in defending overtime claims under the Fair Labor Standards Act based on the “companion” exception

Health Care Contracting Disputes: Represented outgoing exclusive ancillary provider in a suit against a health plan and an in-coming exclusive provider, and obtained rulings which dissolved ex-parte temporary injunctions, forcing the settlement and purchase of all medical equipment in place at patients’ homes throughout the state.

Health Care Partnership Disputes: Successfully represented partners of a healthcare entity in a partnership dispute premised upon the failure of the underlying management agreement to comply with healthcare related laws and regulations

Medicare Advantage Compliance Audits: Represented a Medicare Advantage Plan as to Medicare audit pertaining to claimed MRA related overpayment

Managed Care/Physician Incentive Programs: Represented a managed care organization in creating and implementing a fraud & abuse compliant physician incentive program (PIP)

Managed Care/Network Contracting: Represented ancillary providers in creating statewide DME/HomeHealth/Infusion capitated network which then contracted with most major health plans on exclusive statewide basis

Health Insurance Company Receivership:  Represented principals of Medicare Advantage plan in connection with receivership proceedings, including assistance in feasibility analysis of continued operations and mitigation of personal exposure in connection with receivership.   

Hospital Wind-down:  Represented Hospital in orderly and compliant  wind-down of operations, including discharge of patients, closure of emergency room, discharge of clinical and non-clinical staff, so as to effectuate two (2) year remodel and subsequent reopening of hospital without adversely affecting licensure or CON       

Representative Transactions

MSO: Represented a start-up, physician-owned MSO on all aspects of operations, regulatory compliance, and business issues from commencement until ultimate sale to national HMO

Managed Care: Represented founders of a 200,000 member managed care organization in its sale to a national publicly traded HMO

Hospital: Represented a publicly traded health care company in its acquisition of a 354-bed hospital

HMO: Represented start up HMO in its acquisition of existing Medicaid and commercial HMO

P/E Portfolio Company: Sale of national medical distributor (P/E portfolio company) to another health care focused private equity firm

Medical Center Roll-Ups : Represented a publicly traded healthcare provider in a series of acquisitions of medical and sleep centers throughout the country

Laboratory: Represented a publicly traded clinical and toxicology laboratory in a series of acquisitions of clinical laboratories throughout the country

Medical Center Network:  Represented founders of a network of Medicare Advantage medical centers in sale to private equity firm

Medical Center Network bundled with HMO:  Represented founders of a network of Medicare Advantage medical centers in a bundled sale of network and separately owned HMO to a private equity firm

Medical Center Network Recapitalization:  Represented physician founders of a network of Medicare Advantage medical centers in recapitalization of network through private equity investment but with physicians retaining operational control  

Healthcare Holding Company:  Represented founders of a health holding company with insurance brokerage, medical centers, and discount plan to publicly traded healthcare holding company

Home Health and Hospice:  Represented founders of a multi-state home health and hospice company in sale to private equity firm.

Behavioral Health:  Represented private equity in acquisition of behavioral health platform.