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Health Law: Health Care Providers

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Health Law
Health Care Providers

The Clients: “Health care providers” is a broad umbrella that covers not only the obvious direct service providers (hospitals, clinics and health care workers, etc.), but also managed care companies, health maintenance organizations (HMOs), public insurance providers like Medicaid and Medicare, and private insurers.

The Practice: Representing health care providers covers a broad range of subjects and legal issues. Almost every aspect of the delivery of health care is regulated. Federal and state regulations govern the relationships among health care providers and their patients or the residents in continuing care facilities. Assisted living facilities must be licensed and must carefully negotiate the boundaries between assisted living, skilled nursing and the higher levels of care that may be provided in long-term care facilities. Billing practices of health care providers must also conform to state and federal reimbursement laws. [...]

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The Clients: “Health care providers” is a broad umbrella that covers not only the obvious direct service providers (hospitals, clinics and health care workers, etc.), but also managed care companies, health maintenance organizations (HMOs), public insurance providers like Medicaid and Medicare, and private insurers.

The Practice: Representing health care providers covers a broad range of subjects and legal issues. Almost every aspect of the delivery of health care is regulated. Federal and state regulations govern the relationships among health care providers and their patients or the residents in continuing care facilities. Assisted living facilities must be licensed and must carefully negotiate the boundaries between assisted living, skilled nursing and the higher levels of care that may be provided in long-term care facilities. Billing practices of health care providers must also conform to state and federal reimbursement laws. These and other regulations restrict certain affiliations and joint ventures between health care providers and their vendors or insurers. For example, certain affiliations may affect the tax-exempt status of a health care provider or may compromise its reimbursement for services.

State regulations primarily govern the credentialing of medical staff and impose quality standards for the delivery of health care services. Health care providers must comply with complicated fair hearing procedure requirements in connection with peer review and credentialing. There is also increasing regulation concerning the privacy of health care information, in both the U.S. and the European Union. These rules can constrain the way an organization interacts with its employees, customers, service providers and vendors.

Business Law: A transactional practice serving health care providers entails legal services that are unique to health law, such as physician credentialing, bioethics, and organization of medical staffs and other physician groups. But it tends to be a much broader practice than that. Health law transactional lawyers can cover anything from advising hospitals on antitrust issues to providing tax advice to HMOs to assisting physician groups in forming partnerships.

Essential to most of these practices is a solid understanding of business and contract law. Hospitals may require assistance with corporate formation and governance, financing issues, qualification for tax-exempt status, real estate and employment law issues. Certain larger organizations may need antitrust advice when they consider acquisitions, reorganizations or affiliations. Physician groups may require expertise in corporate and partnership law, as well as employment law and employee benefits. These different health care clients also often need specialized tax expertise, as well as an understanding of the specific state and federal regulatory requirements that govern both their operations and any related business activities.

Litigation: In addition to obtaining a grounding in commercial litigation, students interested in a litigation practice representing health care providers will want to develop an understanding of the regulations affecting this group and some understanding of insurance coverage issues. Private litigation may involve disputes between providers themselves, between providers and third party payers, or between providers and their patients or the residents of continuing care facilities. Among the claims handled by litigators in this area are claims of unfair business practices, professional negligence, or elder abuse.

Representation of private companies in the health care industry may also involve government agency investigations, such as “whistleblower” cases initiated by employees. In these cases, lawyers representing defendant companies need to team with white-collar criminal litigators to negotiate with and litigate against the agencies that regulate a particular area of health care products and services.

Regulation & Enforcement: Students interested in a career in regulation and enforcement may consider employment with one of the federal or state agencies that enforce compliance with healthcare fraud and abuse laws, including requirements regarding the standard of care for patients and other residents of care centers. They investigate and litigate alleged fraud in connection with reimbursement of fees and abusive pricing and marketing practices. Among the regulators and prosecutors are the Centers for Medicare and Medicaid Services, the Office of the Inspector General of the Department of Health and Human Services, the Department of Justice, and state Attorneys General, who may bring cases based on state consumer protection statutes.

 
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