Medicare & Medicaid and Other Government Payors



We leverage our knowledge and relationships to optimize our clients’ opportunities and minimize their risks under Medicare, Medicaid and other government payment programs, guiding them through the evolution of payment reform.

Our Approach

We provide our health care clients with reimbursement advice under the Medicare and Medicaid programs as well as third-party payor managed care contracts, including issues relating to cost reporting, billing compliance and self-disclosures, revenue enhancement and transaction structuring.

Our working relationships with Medicare Administrative Contractors, officials in the regional and central offices of the Centers for Medicare and Medicaid Services (CMS), as well as state Medicaid agencies help us to find answers quickly and achieve the right results for our clients.

Medicare reimbursement services

  • Change of Ownership (CHOW)
  • Provider-based designations
  • Direct and indirect graduate medical education payments
  • 340B Pharmacy Discount Program qualification
  • Disproportionate Share Hospitals
  • Consolidated billing
  • Reassignment rules
  • “Incident to” billing rules
  • Specialty Hospital and Specialty Unit reimbursement
  • Geographic reclassification
  • Wage Index
  • Critical Access Hospitals
  • Sole Community Provider status
  • Timely claims processing issues
  • Rate adjustments and exceptions
  • Third-party liability recovery issues
  • Discrete costing and cost allocation issues
  • PRI/MDS/RUGS case mix issues

Medicaid reimbursement services

  • Certification and Change of Ownership (CHOW)
  • Overpayments, underpayments, recoupments and offsets
  • Contract review/negotiation
  • “Medical Necessity” determinations and claims disallowance appeals

We represent clients in connection with Medicare and Medicaid audits (including RAC, ZPIC and OMIG audits) and administrative hearings and prosecute appeals for individual and groups of providers before the Provider Reimbursement Review Board and in Administrator’s Review and judicial proceedings.

We work with

  • Accountable Care Organizations
  • Health care networks
  • Hospitals
  • Clinics
  • Ambulatory surgery centers
  • Physicians and practice groups
  • Nursing homes
  • Assisted living
  • Adult day care programs
  • Home health agencies
  • Dialysis providers
  • Durable medical equipment (DME) suppliers
  • Ambulance and ambulette companies
  • Pharmacies and laboratories
  • Behavioral health providers
  • Substance abuse providers

Recognitions

  • Ranked in New York and Massachusetts for Healthcare in Chambers USA: America’s Leading Lawyers for Business
  • Ranked nationally in Legal 500 USA—Industry focus: Healthcare
  • Ranked nationally in U.S. News/Best Lawyers “Best Law Firms” in Health Care Law and received metropolitan rankings in Health Care Law in Albany, Boston, New York City and Rhode Island
  • Ranked nationally by Modern Healthcare—Largest Healthcare Law Firm
  • Best Lawyers in America in the field of Health Care law
  • Super Lawyers in the area of Health Care law

Match addresses exactly for off-campus claims or risk denials

Medicare Compliance & Reimbursement | July 10, 2019

This article quotes Chicago Health Care partner Valerie Breslin Montague discussing a new Centers for Medicare and Medicaid Services policy, taking effect in July, that could complicate the billing and reimbursement process for health care providers.

Match addresses exactly for off-campus claims or risk denials

Medicare Compliance & Reimbursement | June 01, 2019

This article quotes Chicago Health Care partner Valerie Breslin Montague discussing a new Centers for Medicare and Medicaid Services policy, taking effect in July, that could complicate the billing and reimbursement process for health care providers.

ACO participants: You want to play, put some skin in the game

Wolters Kluwer | August 09, 2018

Chicago Health Care partner Steven Banghart is quoted in this article for his analysis of a proposed overhaul of the Medicare Shared Savings Program’s approach towards accountable care organizations.

New Hampshire Hospitals Win Challenge to Medicaid Payment Rules

Reuters | April 04, 2018

Litigation department chair Scott O’Connell is quoted in this story involving Nixon Peabody’s representation of an association of New Hampshire hospitals in its successful appeal against the U.S. Centers for Medicare & Medicaid Services. The lawsuit relates to a policy change about how Medicaid payment are calculated.

NH hospitals fight to keep CMS suit win at 1st Circ.

Law360 | November 21, 2017

This article mentions Boston commercial litigation associate Morgan Nighan and Manchester commercial litigation partner and litigation department head Scott O’Connell for representing New Hampshire hospitals in an ongoing dispute involving a Centers for Medicare & Medicaid services reimbursement policy. Scott is also quoted.

Children’s health org backs hospitals in 1st Circ. CMS row

Law360 | November 16, 2017

This article quotes Manchester commercial litigation partner and litigation department head Scott O’Connell and mentions him and Boston commercial litigation associate Morgan Nighan as counsel representing New Hampshire hospitals in a dispute involving a Centers for Medicare & Medicaid services reimbursement policy.

  • Ranked nationally for Health Care in Chambers USA: America’s Leading Lawyers for Business 2018, as well as in Illinois, Massachusetts and New York
  • U.S. News/Best Lawyers has named Nixon Peabody “Law Firm of the Year” in Health Care Law in 2016
  • Ranked nationally in U.S. News/Best Lawyers 2019 “Best Law Firms” in Health Care Law, and received metropolitan rankings in Health Care Law in Albany, Chicago, Long Island, Los Angeles, New York City and Rhode Island
  • Ranked in Illinois, Massachusetts and New York for Health Care in Chambers USA: America’s Leading Lawyers for Business
  • Ranked nationally by Modern Healthcare—Largest Healthcare Law Firm
  • Recognized lawyers by Best Lawyers in America in the field of Health Care law
  • Recognized lawyers by Super Lawyers in the area of Health Care law
  • Recognized by the American Bar Association’s Health Law Section in its Annual Regional Law Firm Recognition Program
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