Skilled Nursing Facilities (SNFs) come in all shapes and sizes in how they are structured and the patients that they serve. As the vast majority of SNFs are certified in both the Medicare and Medicaid programs, Hooper, Lundy & Bookman has high levels of expertise in licensing and certification issues as well as all of the related reimbursement and post-payment issues that SNFs face in ensuring that they are paid timely and appropriately by governmental and third-party payors.
With the increasing trend towards payment systems being moved to managed care, our attorneys are experts regarding the intricacies of negotiating health plan contracts on behalf of SNFs as well as enforcing the terms of those agreements. We have tremendous expertise with respect to the operation of Medicare Advantage and Medicaid managed care plans as well as commercial plans and Accountable Care Organizations. Given the nature of the patients served by SNFs, we have a specific focus on Special Needs Plans (D-SNPs) that are serving dually-eligible beneficiaries, either through the recently enacted Duals Demonstration Program or in markets that have not participated in the demonstration but have significant D-SNP penetration. Our attorneys have also sought reimbursement on behalf of SNFs from health plans in non-contract situations, and other complex contractual situations such as circumstances where a contract has expired by its own terms.
While most SNFs participate in the Medicare and Medicaid programs, they may have slightly different structural aspects based on whether they are “free-standing” or “hospital-based.” Our attorneys are expert in these nuances as well as the additional reimbursement and regulatory issues that arise when SNFs provide subacute services through specialized units, either by entering into separate governmental contracts with Medicaid agencies or operating under existing hospital licensure. With the trend towards managed care payment systems, our attorneys understand the nuances of these structures and patient populations and how they relate to managed care contracting. This likewise applies to the operations of Special Treatment Programs within SNFs (SNF-STPs) and the unique state-county funding of these skilled nursing and mental health services under Medicaid.
Notwithstanding these differences, all SNFs face the growing challenges associated with audits and investigations by governmental payors and health plans. Further, as these activities can produce take-backs from SNFs or produce administrative, civil or criminal filings under the elder abuse or false claims laws, providers need to ensure that their attorneys are fluent with these risks, the governmental investigators involved and can manage these investigations with these interests in mind.
Our attorneys have vast experience in this area, having successfully managed countless investigations through their conclusion or through litigation brought by governmental entities or qui tam relators. These have included audits and investigations handled by State Medicaid Agencies (in California the Department of Health Care Services and the Bureau of Medi-Cal Fraud and Elder Abuse), by the Centers for Medicare and Medicaid Services (“CMS”) and its contracted Medicare Administrative Contractors (MACs), Recovery Auditors (RAs), Zone Program Integrity Contractors (ZPICs), Supplemental Medical Review Contractors (SMRCs), the Office of Inspector General (OIG), the Federal Bureau Of Investigation (FBI)and the Department of Justice (DOJ).
We also have significant expertise with the numerous regulatory issues faced by SNF in their daily operations, as overseen by state licensing authorities (in California, the Department of Public Health) and CMS. These include issues associated with transfer and discharge, self-reporting obligations relating to the delivery of care as well as the retention of overpayments, issues of capacity and informed consent and the myriad other daily legal issues that arise in SNF operations. Whether it is counseling clients or directly handling these matters, we bring a wealth of expertise to these issues.
This is likewise the case with assisting SNFs with their compliance efforts and obligations. We have drafted, reviewed and revised numerous SNF compliance plans and serve as advisors to compliance officers and internal SNF staff in resolving compliance issues.
As civil litigation is an increasing risk for the post-acute and long term care profession, our attorneys regularly manage complex litigation in both state and federal courts at the trial and appellate levels. Our attorneys have managed numerous class actions and representative lawsuits brought under California's Unfair Competition Law (UCL), Business and Professions Code Sections 17200 et seq., the Consumer Legal Remedies Act (CLRA), and other broad statutory claims such as California Health and Safety Code section 1430(b). Given our attorneys' vast experience in managing litigation specific to post-acute and long-term care providers, we also regularly assist providers in risk management and asset preservation strategies through corporate structuring advice and assistance in developing operational policies and procedures.
Beyond the risks associated with operating in this challenging area, our attorneys have significant experience in assisting post-acute care and long term care providers regarding a myriad of business transactions, including mergers, acquisitions, asset sales, joint ventures, financings, real estate transactions, private placements and syndications, health plan and other commercial contracting, and other transactional matters. Not only do our attorneys have the expertise to draft and negotiate the necessary documents to support the transaction, they have a thorough understanding of the due diligence process related to SNF operations and all of the necessary regulatory approvals that need to be obtained from governmental entities to make the transaction operational. We have extensive contacts within the federal and state regulatory agencies that can greatly assist with a transaction going smoothly and meeting our clients’ needs.