Government Payor Defense

• Filed the first federal suit in the country challenging an MCO’s use of generative artificial intelligence (gAI) for a postpayment review to determine denials and an extrapolated overpayment as violation of the Federal Medicaid Act.
• Invalidated two extrapolated overpayments in federal litigation against CMS for audit contractors violating a supplier’s due process rights by failing to produce documentation to support extrapolated overpayments.
• Successfully obtained civil sanctions against CMS in federal litigation for failure to preserve and procedure documentation necessary to support an extrapolated overpayment.
• Successfully overturned a CMS payment suspension against a provider with annual Medicare payments in excess of $100 million and prevented the termination of 3,000 employees and loss of services to 25,000 beneficiaries without federal litigation while the provider was under DOJ investigation.
• Overturned all denials used by HHS-OIG to support a $29 million dollar overpayment and 98% error rate against a durable medical equipment supplier in the Medicare appeals process.
• Reduced a DOJ health care fraud loss value of $80 million in a criminal proceeding to $3.3 million at a fatico hearing.
• Represented a national group of oncology specialty practices before the Department of Veteran Affairs and reduced alleged overpayments by approximately $50 million.
• Defended a CMS Medicare and Medicaid fraud, waste and abuse audit by a Unified Program Integrity Contractor (UPIC) by reducing exposure from $6 million to $155,000.
• Defended a Medicaid fraud, waste and abuse audit and reduced exposure from $1.6 million to $300,000.
• Defended a hospice owned by a health system from a UPIC audit and CMS payment suspension by reducing error rate from 88% to 3%, terminating suspension and having held funds in the amount of $5.5M released.

False Claims Act and Health Care Fraud

• Successfully defended a False Claims Act investigation against a revenue cycle management company that had billed for the targets of the Department of Justice litigation with a global loss value in excess of $180 million.
• Defended free-standing hyperbaric facility from False Claims Act investigation and reduced exposure from $25 million to $450,000 in settlement.
• Testified as an expert witness in federal health care fraud case and reduced defendant’s financial loss value from $18 million to $3.1 million.

International Reimbursement Dispute and Guidance

• Represented an international medical device manufacturer regarding obtaining a billing code and CMS reimbursement guidance.
• Represented foreign hospitals and air ambulances in administrative appeals and pre-litigation resolutions for settlement of health insurance claims by foreign hospitals and air ambulance companies.
• Represented U.S. hospitals and providers in administrative appeals and pre-litigation resolutions for settlement of health insurance claims against foreign insurance carriers and government health plans.

Expert Witness

• Served as an expert witness in a bankruptcy proceeding regarding the compliance of a rural hospital serving as a reference laboratory under CMS regulations and guidance.
• Served as an expert witness for a defendant in a federal criminal health care fraud case regarding Medicaid regulations, reimbursement methodology, and industry standards regarding payment of amounts based on fee schedules versus billed rates.
• Served as an expert witness for physician in arbitration regarding CMS regulations on the necessary elements of physician supervision of an advanced nurse practitioner providing radiation therapy.