Industries & Practices
Health Care Industry
Health system OCR investigation
Assisted health system to respond to OCR investigation, which investigation followed a breach of unsecured patient information. Investigation concluded without ORC finding any violations of the HIPAA rules.
Work closely with medical staff leadership for health system with separate medical staffs on credentialing, privileging, professionalism and effectiveness, quality and peer review matters for medical staffs, GME residents/fellows and advance practice providers.
Medical staff bylaws and governance
Manage and develop medical staff bylaws and governing documents for health systems with unified and/or separate medical staffs to standardize processes and bylaws for credentialing, privileging, peer review and corrective action.
Advise and work closely with medical staff leadership to conduct reviews of medical staff governing bylaws, rule and regulations, policies and procedures for compliance with Medicare conditions of participation, applicable laws and accreditation standards (i.e., TJC, HFAP, DNV/NIAHO) making recommendations for standardization and industry best practices.
Medical staff bylaws overhaul
Complete redraft of medical staff bylaws, rules and regulations, credentialing, peer review and fair hearing policies for a large health system with separate medical staffs.
Graduate Medical Education (GME)
Work closely with teaching faculty and hospital leadership for academic medical centers and teaching hospitals with training programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). Advise and conduct reviews of hospital and GME policies and procedures for sponsoring institution and program compliance with Medicare conditions of participation and ACGME requirements. Developed and negotiated affiliation agreements and program letters for education and clinical training of residents and fellows. Advise and conduct GME appeals/hearings for due process of resident and/or fellow adverse actions in compliance with ACGME requirements and GME policies and procedures for sponsoring institutions and programs.
Peer review and medical staff hearings
Develop peer review processes for medical staffs and practitioners granted clinical privileges with health systems and hospitals.
Represent health systems and hospitals in fair hearings and appeals regarding adverse recommendations for medical staff appointments and/or clinical privileges for medical staff members.
Develop peer review processes for medical staff and practitioners employed by hospital-affiliated entities and create documents that permitted the sharing of peer review information between health systems, hospitals and affiliated entities.
Credentials Verification Organizations (CVO) and Managed Care
Represent health systems and hospitals for initial and recertification of National Committee for Quality Assurance (NCQA) credentialing and CVO certification. Develop and negotiate delegated credentialing agreements on behalf of CVOs and health systems with multiple CMS Certification numbers with managed care plans. Advise and represent CVOs and health systems with multiple CMS Certification numbers on credentialing and CVO policies, enrollment and appeals of participating providers.
Health system and physician-owned hospital affiliation
Prepared several options for a health system and physician-owned surgical hospital to affiliate in a secondary market. Provided regulatory advice, including an analysis of potential Stark Law and Anti-Kickback Statute compliance issues, as well as antitrust and federal tax law advice.
Change of Ownership RAP appeal
Represented a home health agency in its appeal of post-Medicare Change of Ownership Request for Anticipated Payment suspension imposed by the Centers for Medicare and Medicaid Services. Successfully appealed the payment suspension, which was worth $15 million.
Skilled nursing facility bed sale
Represented a health system in its sale of a skilled nursing facility to the management firm of the nursing facility. Formulated potential structures, drafted and negotiated various agreements, and implemented each agreement’s operation. The sale involved a bed purchase agreement, Medicare change of ownership, certificate of need and comprehensive facility and operating lease, as well as several regulatory filings.
HIPAA policy review
Reviewed the HIPAA policies of two regional health plans to ensure continued compliance with relative state laws. These regional health plans were part of a national health plan’s portfolio and also required compliance with the national plan’s policies on HIPAA privacy, security and breaches.
Hospital transition to orthopedic-only center
Assisted a health system in transitioning a hospital campus into a specialty services center, which required engaging physicians on the center’s medical staff to participate in quality improvement and cost reduction efforts. Developed, negotiated and prepared legal structure and contractual arrangements for the health system to engage physicians and ensure compensation at fair market value for these efforts.