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Medicare and Medicaid Coverage and Reimbursement
As leaders in this complex area, our professionals use their knowledge of federal, state and local health care issues to counsel clients on legal and policy matters under federal administrative and regulatory rules, with a particular focus on health care policy initiatives.

PROFESSIONALS
SPECIALTIES

Appropriations and Grant Funding

Fraud and Abuse and False Claims Act Litigation and Counseling

Legislative and Regulatory Policy

Medicare and Medicaid Coverage and Reimbursement

Privacy, HIPAA and Health IT

Transactions
Practice Areas : Health Care : Medicare and Medicaid Coverage and Reimbursement

A central part of our Health Care Practice includes helping clients navigate the overlapping statutes and regulations governing Medicare and Medicaid coverage and reimbursement. Through sophisticated counseling, analysis and advocacy, we help clients obtain coverage and adequate reimbursement for products and services under these programs. We work closely with our Food and Drug team to anticipate and address potential coverage and payment challenges for new products in the pipeline for approval. Attorneys in Patton Boggs’ Litigation and Dispute Resolution Practice are also well-versed in Medicare reimbursement litigation, regularly representing clients in federal court.

Highlighted Successes
  • Achieved core reform for the Medicare ESRD program, including patient education and prevention benefits as well as a permanent annual update mechanism and a ground-breaking program to link payments to quality.
  • Achieved corrected reimbursement levels for client’s pharmaceutical product in the Medicare, Medicaid and SCHIP Extension Act of 2007. 
  • Prevented scheduled payment reductions to ambulance services in the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA). 
  • Achieved “covered drug” classification for a pharmaceutical product previously excluded from coverage under Part D. 
  • Extended the authorization for Medicare Advantage Special Needs Plans in 2007. 
  • Worked with coalition to obtain enactment of $1 billion increase in Medicare reimbursement for dialysis services as part of the MMA and secured an additional $1 billion increase as part of the Deficit Reduction Act of 2005 (DRA), and the Tax Relief and Health Care Act of 2006. 
  • Secured a correction notice from CMS to remedy errors in the CY 2006 Physician Fee Schedule for the dialysis community, thus avoiding a significant cut in Medicare reimbursement. 
  • Improved Medicare reimbursement for certain infections in the hospital inpatient payment system. 
  • Obtained Medicare billing codes for devices to monitor glucose levels in patients with diabetes. 
  • Developed Medicare Part D guidance documents adopted by the agency to protect nursing home residents. 
  • Achieved permanent legislative relieve for rehabilitation hospitals nationwide in the Medicare, Medicaid and SCHIP Extension Act of 2007, addressing the controversial Centers for Medicare and Medicaid Services (CMS) regulatory policy known as the “75% Rule.” 
  • Advanced provisions enacted in the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA) to require the HHS secretary to review current best practices for nursing facility pharmacy services and to report on plans to implement the benefit consistent with these standards. 
  • Advocated provisions of the MMA requiring the HHS secretary to issue rules to encourage convenient access to Part D benefits for residents of long-term care facilities. 
  • Achieved CMS treatment of Puerto Rico as a separate region for Medicare Prescription Drug plans and local Medicare Advantage plans, thus giving beneficiaries access to coverage and avoiding premium increases. 
  • Advanced provisions enacted in the MMA to increase Medicare reimbursement for physicians and hospitals in the Commonwealth of Puerto Rico. 
  • Secured equality in Medicare coverage for certain breast-imaging equipment. 
  • Advocated the adoption of broad CMS requirements for coverage of mental health medications by plans participating in the Medicare prescription drug benefit program. 
  • Secured enactment of language in Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), eliminating the three-year limit on Medicare immunosuppressive drug coverage for the aged and disabled populations. 
  • Obtained language restoring Medicare reimbursement levels for Skilled Nursing Facilities and Home Health in BIPA. 
  • Achieved inclusion of the colorectal cancer screening benefit in the Balanced Budget Act of 1997 (BBA), and an expansion of the benefit in the Balanced Budget Refinement Act of 1999 (BBRA).
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