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


  • 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

Hospitals seek legal cover amid their coronavirus responses

Healthcare Financial Management Association | March 24, 2020

Washington, DC, Health Care counsel Sarah Swank discusses how waivers from the Centers for Medicare and Medicaid Services have allowed hospitals to pursue flexible approaches to patient care during the wave of COVID-19 infections.

California guidelines advance telehealth for Medicaid patients

Law360 | September 17, 2019

Los Angeles Health Care partner Jill Gordon and associate Harsh Parikh co-wrote this contributed article looking at new state guidelines that will expand Medicaid reimbursement for telehealth services.

Hospitals lobby to delay DSH funding cuts as October 1 deadline looms

Crain’s New York | September 06, 2019

In this story, Litigation Department Head Scott O’Connell offers his perspective on new financial uncertainty for hospitals as an October deadline looms to avoid large cuts to federal funding for facilities that treat large numbers of Medicaid and uninsured patients.

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.

  • 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
  • Recognized lawyers by Best Lawyers in America in the field of Health Care law
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