Disruption and innovation mark the health care industry like never before. Our Health Care Team works with a wide variety of clients - large and small, established and start-up, provider and vendor - as they bring forth novel solutions to the challenge of providing better health outcomes to a broader population at a lower cost. As an entrepreneurial law firm, PLDO instinctively grasps the need for established entities to design new strategies, and for new and growing entities to expand in spaces that did not exist even a decade ago. A health care law team must retain the traditional set of skills and experience that will continue to deliver value across time. However, what sets PLDO's Health Care Team apart is our ability to translate that experience into innovation. By understanding where the industry has been and why prior efforts have failed, our team can better assist clients in positioning themselves for the inevitable changes to come, and for the corresponding market share and profit that can be captured as a result.
Health Care Franchising and Management Service Organizations
Physicians and dentists are at a breaking point. The avalanche of government and payor regulations, paper-thin reimbursements, and fleeting patient encounters spent typing into the EMR has brought physician satisfaction to an historic low. Over twenty percent of new physicians refuse to accept new Medicare patients, and 15 percent refuse new privately-insured patients. Further, the hoped-for relief of hospital-based or large-group employment has increasingly proven illusory. PLDO's Health Care Team works with physicians and dentists to capitalize on the growth of a powerful alternative: health care franchising and management service organizations (MSOs). Franchises and MSOs seem destined to flourish given the expanded role for Health Savings Accounts that underlies repeal of the ACA. Whether helping a practitioner identify and join a best-fit franchise or MSO, or guiding practitioners and investors through the complex but rewarding process of establishing a nationally-compliant franchise or MSO of their own, the PLDO Health Care Team is ideally positioned to help clients maximize the potential of this rapidly-growing aspect of the health care delivery system.
Monetizing Health Care Data
The greatest difference between the growth of integrated delivery systems today and those that failed at the turn of the century is the ability of modern payors and providers to monetize health care data: to utilize data in a way that contributes meaningfully and cost-effectively to the entity's mission and its bottom line. The health care delivery system is constantly evolving in response to our ability to find new uses for data, many of which involve the structuring of new relationships and all of which involve the risk of unauthorized access, use and disclosure. Many of the greatest innovations in health care delivery are coming from the IT platforms and vendors that the PLDO Health Care Team serves. The success of the Triple Aim, and of the HIPAA-covered entities and business associates playing a part in that endeavor, is based upon the ability to turn data into information, information into insight, and insight into action.
The PLDO Health Care Team has decades of expertise in the areas of business structure, real estate, joint ventures, mergers and acquisitions, and corporate or business-line start-ups. We routinely assist our clients in structuring new organizations or ventures, dealing with corporate governance and regulatory compliance issues, and developing compliance programs that keep those organizations and ventures on the right side of the law. Many of the attorneys at the firm also serve as board members for numerous nonprofit organizations as a way of giving back to the community.
Regulatory Compliance, Reimbursement and Representation
The implementation of effective compliance programs and preventing unwanted enforcement actions must always be top priorities. We assist clients in implementing not merely with compliance programs, but also with enterprise risk management programs designed to identify where those compliance programs might be at risk. As the HHS OIG has made clear, a "paper program" offers no value: an effective compliance program must be alive and proactive in order to serve as a mitigating factor in an enforcement action. Further, an effective compliance program will not only avoid the crushing costs that come with even a minor False Claims Act violation, it can also have the welcomed effect of enhancing the organization's bottom line. Coding and billing properly also means that no allowable reimbursement "falls through the cracks."
Members of our Health Care Team have assisted clients in developing and implementing effective compliance programs since the HHS OIG issued its first Compliance Program Guidance in 1998. The PLDO Health Care Team also represents providers before governmental agencies, review boards and administrative agencies in dealing with issues ranging from Certificates of Need to payment appeals.
Fraud and Abuse and HIPAA
Several Health Care Team members are former prosecutors, with extensive experience in prosecuting and defending against fraud and abuse charges that easily arise in billing initiatives, joint ventures, incentive programs and contractual relationships with providers. The health care industry is a minefield of rules and regulations, all of which present potential liability to the provider, including:
- Gainsharing under the Civil Monetary Penalties Act
- The Anti-Kickback Statute
- The Stark Law
- The False Claims Act
- The qui tam whistleblower statute
- Health Insurance Portability and Accountability Act (HIPAA) privacy and security provisions
- The Fraud Enforcement and Recovery Act
- The Patient Protection and Affordable Care Act
- Corresponding state laws
Our Health Care Team is experienced in dealing with the Department of Justice, the Health and Human Services Office of the Inspector General (OIG) and Office of Civil Rights (OCR), Medicare administrative contractors, state prosecutors and Medicaid agencies in defending against enforcement actions, health care fraud criminal charges, investigations, agency audits and repayment demands. In fact, our Health Care Team successfully negotiated one of the nation's few Deferred Prosecution Agreements implemented in a health care setting.
Labor & Employment Issues in Health Care
Health care providers are among the most labor-intensive of employers and face a unique combination of labor and employment concerns. They deal with ERISA issues and employee benefit plans, HIPAA, state privacy laws and patient-safety laws, and what may be a straight-forward labor or employment law question in another industry can be fraught with legal peril when faced by a health care entity. Our Health Care Team has decades of experience in the unique world of health care-related labor and employment issues.
To learn more about how PLDO can help you address your health care law issues, contact us.