Medicaid & Medicare Contracts

Medicaid and Medicare Contract Law

Throughout the health care industry, many companies have contracts with federal or state governments to provide health care or health care services to certain communities or individuals in exchange for reimbursement of such care or services from the government. Many different laws and regulations apply to companies who have such contracts. These laws and regulations set forth detailed rules on how such companies must conduct business and what they need to do in order to maintain their contracts. Sometimes, governments investigate these companies upon receipt of a complaint or accusation about the company, and questions or concerns about fraud or false billing follow. See also MO HealthNet & Medicaid.

The Law Offices of Kevin J. Dolley has represented many clients in matters involving claims of Medicare and Medicaid fraud, including but not limited to False Claims Act and qui tam litigation. The Firm has substantial experience representing health care providers and other clients in the State of Missouri who have been accused of engaging in fraudulent or false billing and other business practices. No matter the situation, we understand the landscape of federal and state laws that will directly impact your rights and options. Often, these types of matters require quick and decisive action to avoid irreparable harm. We bring a wealth of knowledge and experience to the table in handling such matters, which enables us to act quickly to pursue or protect your rights and interests.

Missouri Medicaid Payment Suspension

We have represented many Missouri health care providers who have received a Notice of Medicaid Payment Suspension. If you have been advised by the Department of Social Services, Department of Health and Senior Services or other Missouri Department that your Missouri Medicaid number was suspended, it is critical to immediately retain legal counsel and act quickly. Suspension of payments often have serious adverse effects which continue past the period of suspension. We have monitored the developments and changes in this area of law over the years and know how to best safeguard your rights as an approved Medicaid provider.

Missouri law and regulations allow a health care provider to appeal the government’s decision to implement a Medicaid payment suspension and, under certain circumstances, to obtain an immediate stay of the suspension. Securing a stay order is often very important to a client, as it may allow the client’s business to remain in operation while the allegations of billing fraud or irregularities are sorted out and decided through formal legal proceedings. However, having legal knowledge and experience of how, when, and where to pursue such an order is often integral to your likelihood of success.

The Affordable Care Act ("ACA") effectuated changes to federal law that impact how and when state government agencies may implement immediate suspensions of payments to health care providers. Previously, state government agencies had more discretion as to whether to withhold payments to providers; suspensions were triggered by “receipt of reliable evidence.” However, since the changes effectuated by the ACA, Medicaid payment suspensions are easier to implement: if the agency determines there is a pending investigation for a “credible allegation of fraud,” it must suspend payments, absent good cause. 42 C.F.R. § 455.23(a)(1); see also § 208.164 RSMo.

One practical effect of this change that many believe has occurred is that the Missouri Medicaid Audit and Compliance Unit (“MMAC”)—the Missouri agency entrusted with investigation and enforcement of Medicaid fraud claims— can now arguably suspend payments to providers under Medicaid based on less information or evidence, prior to a formal adjudication of the claims of fraud. This raises a host of due process concerns for businesses who rely, in whole or in part, upon timely receipt of Medicaid payments, pursuant to their contracts with the government, in order to provide necessary care and support to underserved or disadvantaged communities.

Our Firm has the knowledge and ability to act swiftly to seek immediate injunctive relief before the Missouri Administrative Hearing Commission (“AHC”) in order to try to avoid or minimize business disruptions while the matter can be more appropriately addressed based upon the factual circumstances in the context of a formal legal process. This is critical to ensure that providers have a meaningful opportunity to examine and respond to the “credible allegations of fraud” before a neutral Commissioner with the AHC or through negotiation with the Medicaid.

Contact Us

If you have questions or concerns regarding potential fraud or false billing in connection with Medicare or Medicaid payments, contact Mr. Dolley directly at (314) 645-4100 or by email at kevin@dolleylaw.com.

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