OUR HEALTH CARE LAW PRACTICE
The health care law practice of The Martin Law Firm, P.C. provides transactional and litigation services for all types of licensed health care providers. We provide legal solutions for Physicians, Chiropractors, Nurse Practitioners, Physician Assistants, Physical Therapists, Massage Therapists, Speech Language Pathologists, Dentists, and DMEPOS suppliers. The Martin Law Firm, P.C. also represents state associations whose members are licensed providers, practice management companies, electronic health record software vendors, and medical billing companies. Our health care attorneys help providers navigate through the complex statutes, regulations, and policies that govern the various health care professions.
LITIGATION, AUDITS AND OVERPAYMENT DETERMINATIONS
To reduce fraud, waste and abuse within the health care system, Medicare, Medicaid and commercial insurance payers routinely perform retroactive audits of claims submitted by healthcare providers to determine whether the providers submitted “clean” claims for reimbursement.
These audits begin with a request for medical records which are then sent to a consultant for review. The consultant will identify non-compliance with billing, coding and documentation rules and policies in order to justify an overpayment determination. The payer will then demand a return of the overpayments directly from the provider or, in some instances, will offset the overpayment amount against current and future claims submitted by the provider.
The Martin Law Firm, P.C. represents health care providers by appealing and challenging the payer’s retroactive claim denials. We utilize our knowledge of the law, our experience and understanding of payer policies and guidelines, and our network of coding and compliance experts to create an effective rebuttal to retroactive claim denials. Over the years we have saved health care providers millions of dollars in retroactive claim determinations. Click the following links for more information on retroactive audits and appeals:
- Medicare Audits and Appeals
- Insurance Audits
- Highmark Audits
The Martin Law Firm, P.C. creates and implements Compliance Programs for health care providers. A Compliance Program is a written source of information for health care providers that incorporates laws, policies and guidelines that relate to reimbursement matters such as billing, coding and documentation as well as state and federal health care laws that impact the daily practice of licensed practitioners.
In 2000, the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) established compliance program guidance.
The Martin Law Firm, P.C. has developed and maintained the standards that all providers and small group practices should implement to avoid retroactive audits and mitigate the impact of an audit. Cookie cutter or “off-the-shelf” Compliance Programs are ill-advised. Our Compliance Programs are specially tailored for each licensed professional (M.D., D.C. P.T., etc.) and are designed to be the main source of information for providers who want to increase and protect their reimbursement.
PROFESSIONAL LICENSURE AND DISCIPLINARY PROCEEDINGS
The Pennsylvania Department of State’s Bureau of Professional and Occupational Affairs is tasked with protecting the health and safety of the public from fraudulent and unethical health care practitioners.
In Pennsylvania, there are 29 licensing boards and commissions (e.g. medical board, chiropractic board, etc.) who govern licensed healthcare providers. These boards and commissions are specifically authorized by separate statute to create regulations, define scope of practice, and establish rules of conduct.
When a health care provider is alleged to have violated a rule of conduct, the Pennsylvania Bureau of Enforcement and Investigation provides the boards and commissions with inspection, investigation and law enforcement capabilities. The investigations can lead to prosecutorial action by the Office of Chief Counsel’s Prosecution Division and a formal hearing conducted by the licensing board which will determine whether disciplinary action is warranted. Disciplinary action can lead to license suspension, revocation, and fines. The Martin Law Firm, P.C. defends health care providers who are being investigated and prosecuted.
HEALTH CARE PRACTICE ACQUISITIONS
The Martin Law Firm, P.C. represents buyers and sellers of health care practices. Buying or selling a healthcare practice, whether it is a medical office, chiropractic office, physical therapy clinic, or other professional practice, requires expertise in many crossover areas of law. A practice acquisition may trigger corporate practice of medicine laws, statutes and regulations governing the particular licensure, business and corporate law, and contract law. Our Health Law attorneys have the experience in these matters to provide effective representation for our clients. We also utilize business valuation experts and tax experts to help our clients.
PENNSYLVANIA ACT 6 APPEALS
The Pennsylvania Motor Vehicle Financial Responsibility Law (MVFRL) sets forth the standards and responsibilities for insurers who issue insurance policies that protect those who are involved in automobile accidents. Amendments to the MVFRL known as “ACT 6” specifically assigns reimbursement rates for health care providers who treat accident victims and mandates claims payment and processing requirements for the insurers. For example, when an insurer has reason to believe that a health care provider’s services are not reasonable and necessary; the insurer cannot simply withhold payment. The insurer must comply with the peer review procedures set forth in Act 6 of the MVFRL.
Insurers often use the peer review process to deny payment to deserving healthcare providers. Sometimes, the insurers try to circumvent the procedural requirements for conducting a peer review, which can lead to a claim by the provider for payment for services, triple damages, and reimbursement of attorney’s fees and costs. Healthcare providers often exercise their appeal rights to overturn a negative peer review so that they can rightfully receive payment for their services. The Martin Law Firm, P.C. routinely brings civil actions against automobile insurers on behalf of health care providers so that the providers can get paid. Click on the link below to learn more about peer reviews in Pennsylvania.
- Act 6 Peer Reviews and Appeals
Health care providers who want to set up their own practice should consult with an attorney who can provide advice and guidance on whether to form a limited liability company or a professional corporation, compliance, hiring employees and independent contractors, identifying the rights and responsibilities of owners and managers, credentialing, and reimbursement matters.
The Martin Law Firm, P.C. health care attorneys assist licensed health care providers navigate through the complex web of health care laws and regulations, contract law, and business and corporate law to properly set up a health care practice. We pride ourselves on our attention to detail through written ownership agreements, employment and independent contractor contracts and compliance guidance to help licensed practitioners maximize their business opportunity and focus on health care.
- Health Care Practice Formation
Physicians, chiropractors, podiatrists, physical therapists and other healthcare providers face a constantly evolving and highly regulated industry. Additional regulations and changes within the healthcare industry often compel the provider to expand his or her practice.
For individual and small groups, licensed providers often see the value in a multidisciplinary practice. A multidisciplinary practice is an entity that combines two or more types of providers that offer multiple healthcare services, e.g., MD/DC practice. A multidisciplinary practice offers patients comprehensive medical care. Patients with various health problems may be able to receive chiropractic care and medical care at the same location, which facilitates a holistic approach to care and convenience. Setting up a multidisciplinary practice requires health care law expertise due to the numerous statutes and regulations governing the healthcare industry. The Martin Law Firm, P.C. has the experience necessary to set up a proper multi-disciplinary practice that complies with Federal and State laws and regulations.
FEDERAL AND STATE LAWS
Our health care attorneys routinely advice and consult with clients on Federal and State laws that impact the decisions and behaviors of a health care practice and the licensed providers who provide services to patients. These laws often regulate marketing and advertising, fee splitting, improper referrals, and proper claims submissions. The following laws are complex in their application and can result in severe fines and penalties for violations.
- Federal Stark Law
- Federal Anti-Kickback Statute
- Federal False Claims Act
- Qui Tam
- Pennsylvania Insurance Fraud Prevention Act
If you are a health care provider who needs legal assistance and representation, please call the health care attorneys at The Martin Law Firm, P.C. today at 215-687-4053.