Practice Areas

Medicaid
Funding Programs

Eyman Associates has particular legal and practical expertise in helping providers support their missions through the Medicaid program. We have a sophisticated technical understanding of the web of financing streams available to Medicaid providers and the complex requirements governing their use. Such an understanding is critical to preserving these essential funding streams as state Medicaid programs evolve. Disproportionate share hospital payments, graduate medical education payments, other supplemental (“upper payment limit” or “UPL”) payments, supplemental physician payments, waiver-based payment pools, and managed care payments have all proved to be major lifelines for our clients, and will continue to be critical as coverage expands and Medicaid grows. At the same time, these programs require viable and permissible funding sources for the state’s share of these payments—including intergovernmental transfers, certified public expenditures and state and local provider taxes—especially as states’ ability to devote general revenue funds to this support dwindles. Our experience working with Medicaid programs in over 30 states, and our knowledge of evolving and often unwritten federal policies, provides our clients with key insights and strategies for using Medicaid to fund their mission.

Delivery System Reform

The Medicaid program offers a number of levers through which states can promote transformation of the health care delivery system to enhance access and quality, particularly for low income and vulnerable populations. It’s not enough just to import models developed for the commercial or Medicare markets into Medicaid—the vast differences in population present challenges requiring unique approaches. Eyman Associates has worked extensively with providers and with states to develop and implement tailored programs to promote quality, access and value in Medicaid, through state plan amendments, waivers (particularly Delivery System Reform Incentive Payments (DSRIPs) and related programs), managed care contracting and other mechanisms. Contact us to learn more about how Medicaid can support your redesign goals.

Coverage

Has your state expanded Medicaid yet? If not, your challenges are likely multiplying as uncompensated care grows and federal support dwindles. Eyman Associates can help develop creative approaches to expanding Medicaid to address state concerns about resources, incentives, cost, financing, efficiency quality and promoting the private sector. And whether or not your state has expanded Medicaid, we can work with you to reduce gaps, smooth transitions and expand coverage among and between programs including Medicaid, Medicare, dual eligibility, Marketplace Exchanges, Basic Health Program, Section 1332 waiver programs and state and local initiatives.

Waivers

States are increasingly operating their Medicaid programs through federal waivers. Waivers provide maximum flexibility to design unique programs, test out new approaches and implement innovations unconstrained by federal laws and policies written in a different era with a vastly different programmatic model in mind. Medicaid waivers are subject to federal approval through a process that, despite efforts to the contrary, lacks basic transparency. Understanding the process, the often unwritten approval criteria, the necessary design elements, and key concepts such as budget neutrality and expenditure authority is difficult if not impossible without the assistance of an experienced guide. Eyman Associates has been deeply involved in the development and implementation of Medicaid waivers since the early 1990s. We have witnessed their evolution from early state based coverage expansions such as TennCare through the more recent innovations in transforming delivery systems through Delivery System Reform Incentive Payment (DSRIP) programs, regional care organizations and related system redesign initiatives. See our related Resource Page on DSRIP programs. We can help guide you through the waiver amendment or renewal process, help you understand the contours of existing waiver programs and help design and implement new programs.

Managed Care

Over two-thirds of Medicaid beneficiaries are now enrolled in managed care systems, which present a new set of opportunities and challenges for states, providers and beneficiaries alike. In April 2016, CMS finalized an overhaul of federal regulations governing Medicaid managed care, which will have an enormous impact on the way states run their programs. Eyman Associates attorneys have been deeply involved in federal policymaking in the Medicaid managed care arena since before the first set of comprehensive managed care laws were adopted in the Balanced Budget Act of 1997. We can bring that depth of experience to bear in helping you develop and flourish in a Medicaid managed care environment.

 

Medicare

We appreciate how critical Medicare reimbursement is to our clients. Eyman Associates has decades of experience helping clients navigate complex Medicare payment policies, with particular expertise in Medicare disproportionate share hospital (DSH) payments, graduate medical education (GME) payments, and payment programs intended to promote quality, value and efficiency in the Medicare program, including through value-based purchasing, accountable care organizations and the like. Given our involvement on the policy side as an advisor to America’s Essential Hospitals, we often bring unique insight to bear as we assist clients in understanding and maximizing Medicare reimbursement.

 

340B Drug Pricing Program

The 340B Drug Pricing Program has become increasingly critical to the ability of hospitals, federally qualified health centers, and other eligible providers, particularly safety net providers, to finance their pharmacy programs and other missions. Since its creation in 1992, the program has evolved into an enormously complex set of rules governed almost exclusively by informal guidance—leading to significant recent pressure from Congress and oversight agencies for more transparency and accountability.

The Office of Pharmacy Affairs is in the process of finalizing a new omnibus guidance that could for the first time elaborate on many of these informal rules, while also significantly restricting the permissible uses of the program and increasing the consequences of non-compliance for providers. In addition, OPA continues to expand its audits of covered entities and to issue findings based on such rules—the results of which can have massive financial implications.

Developing, documenting and defending a compliant program that meets your needs requires expertise of counsel who have been on the ground as the program has developed, and continue to work with OPA officials on a regular basis to understand the nuances of shifting and still often undefined program rules. Eyman Associates has been deeply involved in the development of 340B policy at a national level for America’s Essential Hospitals and in working with individual providers and systems to navigate these shifting rules. Find out how we can help ensure the benefit of the 340B drug pricing program to serve your critical missions.

Fraud & Abuse

Hospitals serving Medicare and Medicaid beneficiaries must comply with widely varying and highly technical billing requirements and federal and state fraud and abuse laws, including self-referral, anti-kickback, civil monetary penalty, and fee-splitting laws. Eyman Associates regularly applies these laws in a variety of contexts, including in connection with the adoption of innovative payment models, participating in delivery system reform, structuring affiliations, and maintaining compliant relationships among hospitals, physicians, vendors and other health care providers and suppliers.

As you structure new business practices, Eyman Associates can assist in ensuring compliance with complex billing and fraud and abuse laws, as well as assessing the compliance risks of your organization more generally. And when necessary, we represent clients in connection with administrative proceedings related to disallowances and other adverse agency and legal actions.

Academic Medical Centers

Eyman Associates attorneys routinely advise and counsel teaching hospitals, universities, and faculty practice organizations that comprise academic medical centers (AMCs). We take into account the interdependent missions of and relationships among AMC components as we advise AMC clients on all aspects of health law, including Medicare and Medicaid reimbursement, compliance and regulatory matters, and health care transactions and contracting.

We also have extensive experience counseling AMC clients on issues unique to academic medicine, including academic affiliations, GME reimbursement, and research. Given that many of our AMC clients rely heavily on Medicaid reimbursement to support their mission, we frequently assist AMCs in structuring affiliations and funds flow arrangements to comply with federal Medicaid requirements related to Medicaid supplemental payments.

Innovative Payment Models

Medicare, Medicaid and commercial payers alike are all moving to create new payment models that shift away from paying for volume and towards paying for improvements in quality, efficiency, and coordination. The federal Department of Health and Human Services has taken a lead in this effort, setting an ambitious goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018.

Providers are wrestling with an array of new hospital reimbursement programs, including the readmissions program, as well as massive changes in physician payments under the Medicare Access & CHIP Reauthorization Act of 2015—including the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models. In Medicaid, an array of tools are available to create payment models that incentivize and sustain provider investments in changing the delivery of care and improving quality and coordination.

Eyman Associates has decades of experience helping clients navigate complex payment policies, and is strategically positioned to understand the nuances of new programs as they are developed at the federal and state level and leverage that expertise on your behalf. See our Medicaid and Medicare practice areas for further information.

Innovations in Care Delivery

Our clients are by necessity and mission constantly looking for options to improve their ability to reach their patients and deliver care in high quality, efficient, and sustainable ways. The Medicaid program in particular has proven to be a flexible tool to create and support the new care models that can then be extended to additional patients and payers. See our work on Waivers in the Medicaid practice area for additional information on how Eyman Associates can help you design and implement new programs to meet your care delivery goals.

Our Clients

We represent a diverse array of providers, trade associations, academic medical centers, states and others serving a critical role in shaping health care policy and delivering health care services in an era of increasing complexity and challenges.

Our Services

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Legislative and
Administrative Advocacy
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Transactions and Affiliations
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Strategic Consulting
and Development
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Risk Assessment and Compliance
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Regulatory Counseling
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Denials/ Disallowances/ Appeals

Health Care Lawyers in Washington D.C.