Managed Care
Managed Care
As managed care continues to grow and evolve, our clients remain focused on delivering high-quality and cost-effective healthcare in an environment that is subject to heightened scrutiny and enforcement. The attorneys in our multi-disciplinary Managed Care practice have the knowledge and experience necessary to advise clients on the full spectrum of business, legal, and compliance issues impacting the industry. We partner with our clients to navigate this complex regulatory environment and to mitigate risk.
Our attorneys bring federal agency and private defense experience to enforcement and litigation matters involving, for example, the False Claims Act (FCA), Anti-Kickback Statute (AKS), Stark Law, administration of the Part D drug benefit, and Medicare Advantage risk adjustment. We advise companies on internal and governmental investigations involving the U.S. Department of Justice, Centers for Medicare and Medicaid Services, Office of Inspector General for U.S. Department of Health and Human Services, and others. We represent clients in disputes between healthcare providers and payors involving contract disputes, payment issues, out-of-network claims, medical necessity denials, network exclusion, ERISA, and prompt pay laws.
Our practice also draws on the firm's deep bench of healthcare regulatory and reimbursement attorneys for matters important to managed care organizations. We provide compliance counseling focused on holistic assessments of enterprise risk to develop mitigation strategies. In privacy and cybersecurity, we assess risks and offer program design or enhancements as well as advising on data breach response, including conducting investigations and developing notifications for affected individuals. We also advise on strategic transactions including mergers and acquisitions and joint ventures, as well as contract negotiations, bankruptcy and restructuring, and antitrust considerations. We assist clients with responding to governmental inquiries, including subpoenas, and self-disclosures to federal and state regulatory agencies.
We counsel a variety of clients, including:
- Health plans
- Pharmacy benefit managers
- Pharmacies
- At-risk providers
- Electronic health record organizations
- Other vendors interacting with plans and providers in the managed care space
Areas of Focus
- Medicare/Medicaid compliance, including risk adjustment data validation (RADV) audits
- Compliance program assessment, development and implementation
- Provider-fraud detection and remediation
- Quality metrics, including HEDIS/STARs reporting
- Management services organization (MSO) relationships
- Overpayment Rule Telehealth
- Affordable Care Act
- Medical loss ratio
- No Surprises Act
- Medicare Advantage risk adjustment
- Antitrust
- Benefits and coverage
- Labor and employment
- IT vendor disputes
- Provider disputes
- Cybersecurity risk assessment, program design, and enhancement
- Data breach response, including investigation and notification
- Creation of incident response plans
- Analysis of adequacy of protections for data on cloud
- Review of data-sharing arrangements involving PHI and other regulated health data
- Health information exchanges
- HIPAA and state privacy laws
- Mergers, acquisitions, joint ventures, and other transactions
- Deal due diligence
- Contract negotiations
- Antitrust considerations
- Bankruptcy and restructuring
- Tax structuring
As managed care continues to grow and evolve, our clients remain focused on delivering high-quality and cost-effective healthcare in an environment that is subject to heightened scrutiny and enforcement. The attorneys in our multi-disciplinary Managed Care practice have the knowledge and experience necessary to advise clients on the full spectrum of business, legal, and compliance issues impacting the industry. We partner with our clients to navigate this complex regulatory environment and to mitigate risk.
Our attorneys bring federal agency and private defense experience to enforcement and litigation matters involving, for example, the False Claims Act (FCA), Anti-Kickback Statute (AKS), Stark Law, administration of the Part D drug benefit, and Medicare Advantage risk adjustment. We advise companies on internal and governmental investigations involving the U.S. Department of Justice, Centers for Medicare and Medicaid Services, Office of Inspector General for U.S. Department of Health and Human Services, and others. We represent clients in disputes between healthcare providers and payors involving contract disputes, payment issues, out-of-network claims, medical necessity denials, network exclusion, ERISA, and prompt pay laws.
Our practice also draws on the firm's deep bench of healthcare regulatory and reimbursement attorneys for matters important to managed care organizations. We provide compliance counseling focused on holistic assessments of enterprise risk to develop mitigation strategies. In privacy and cybersecurity, we assess risks and offer program design or enhancements as well as advising on data breach response, including conducting investigations and developing notifications for affected individuals. We also advise on strategic transactions including mergers and acquisitions and joint ventures, as well as contract negotiations, bankruptcy and restructuring, and antitrust considerations. We assist clients with responding to governmental inquiries, including subpoenas, and self-disclosures to federal and state regulatory agencies.
We counsel a variety of clients, including:
- Health plans
- Pharmacy benefit managers
- Pharmacies
- At-risk providers
- Electronic health record organizations
- Other vendors interacting with plans and providers in the managed care space
Areas of Focus
- Medicare/Medicaid compliance, including risk adjustment data validation (RADV) audits
- Compliance program assessment, development and implementation
- Provider-fraud detection and remediation
- Quality metrics, including HEDIS/STARs reporting
- Management services organization (MSO) relationships
- Overpayment Rule Telehealth
- Affordable Care Act
- Medical loss ratio
- No Surprises Act
- Medicare Advantage risk adjustment
- Antitrust
- Benefits and coverage
- Labor and employment
- IT vendor disputes
- Provider disputes
- Cybersecurity risk assessment, program design, and enhancement
- Data breach response, including investigation and notification
- Creation of incident response plans
- Analysis of adequacy of protections for data on cloud
- Review of data-sharing arrangements involving PHI and other regulated health data
- Health information exchanges
- HIPAA and state privacy laws
- Mergers, acquisitions, joint ventures, and other transactions
- Deal due diligence
- Contract negotiations
- Antitrust considerations
- Bankruptcy and restructuring
- Tax structuring
Experience
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We conducted due diligence and regulatory analysis for a Medicare Advantage plan in connection with multiple transactions involving multispecialty physician...
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We represented a Fortune 50 healthcare company in conducting oversight of network provider marketing practices and compliance with Medicare marketing...
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We represented a Medicare Advantage Organization and its wholly-owned provider group in an internal investigation related to allegations of improper...
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We represented a Medicare Advantage Organization in an investigation related to data-driven coding anomalies and practices detected at a large...
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We represented a national healthcare company in an investigation related to allegations of fraudulent risk adjustment coding practices. Matter involved...
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We represented a Medicare Advantage plan in multiple internal investigations related to its grievance and appeal procedures.
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We represented a large national healthcare company in its defense of a FCA qui tam involving its wholly-owned Pharmacy Benefit...
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We represented a national managed care organization in an internal review of potentially improper home health and hospice discharge protocols.
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We developed and implemented compliance protocols, strategies, and data-driven analytics for a Medicare Advantage plan to conduct oversight of network...
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We represented a managed care organization in a review of whistleblower allegations related to the post-acquisition integration of a specialty...
Experience
-
We conducted due diligence and regulatory analysis for a Medicare Advantage plan in connection with multiple transactions involving multispecialty physician...
-
We represented a Fortune 50 healthcare company in conducting oversight of network provider marketing practices and compliance with Medicare marketing...
-
We represented a Medicare Advantage Organization and its wholly-owned provider group in an internal investigation related to allegations of improper...
-
We represented a Medicare Advantage Organization in an investigation related to data-driven coding anomalies and practices detected at a large...
-
We represented a national healthcare company in an investigation related to allegations of fraudulent risk adjustment coding practices. Matter involved...
-
We represented a Medicare Advantage plan in multiple internal investigations related to its grievance and appeal procedures.
-
We represented a large national healthcare company in its defense of a FCA qui tam involving its wholly-owned Pharmacy Benefit...
-
We represented a national managed care organization in an internal review of potentially improper home health and hospice discharge protocols.
-
We developed and implemented compliance protocols, strategies, and data-driven analytics for a Medicare Advantage plan to conduct oversight of network...
-
We represented a managed care organization in a review of whistleblower allegations related to the post-acquisition integration of a specialty...
Notice
Visiting, or interacting with, this website does not constitute an attorney-client relationship. Although we are always interested in hearing from visitors to our website, we cannot accept representation on a new matter from either existing clients or new clients until we know that we do not have a conflict of interest that would prevent us from doing so. Therefore, please do not send us any information about any new matter that may involve a potential legal representation until we have confirmed that a conflict of interest does not exist and we have expressly agreed in writing to the representation. Until there is such an agreement, we will not be deemed to have given you any advice, any information you send may not be deemed privileged and confidential, and we may be able to represent adverse parties.
Notice
Visiting, or interacting with, this website does not constitute an attorney-client relationship. Although we are always interested in hearing from visitors to our website, we cannot accept representation on a new matter from either existing clients or new clients until we know that we do not have a conflict of interest that would prevent us from doing so. Therefore, please do not send us any information about any new matter that may involve a potential legal representation until we have confirmed that a conflict of interest does not exist and we have expressly agreed in writing to the representation. Until there is such an agreement, we will not be deemed to have given you any advice, any information you send may not be deemed privileged and confidential, and we may be able to represent adverse parties.
Notice
Visiting, or interacting with, this website does not constitute an attorney-client relationship. Although we are always interested in hearing from visitors to our website, we cannot accept representation on a new matter from either existing clients or new clients until we know that we do not have a conflict of interest that would prevent us from doing so. Therefore, please do not send us any information about any new matter that may involve a potential legal representation until we have confirmed that a conflict of interest does not exist and we have expressly agreed in writing to the representation. Until there is such an agreement, we will not be deemed to have given you any advice, any information you send may not be deemed privileged and confidential, and we may be able to represent adverse parties.
Notice
Visiting, or interacting with, this website does not constitute an attorney-client relationship. Although we are always interested in hearing from visitors to our website, we cannot accept representation on a new matter from either existing clients or new clients until we know that we do not have a conflict of interest that would prevent us from doing so. Therefore, please do not send us any information about any new matter that may involve a potential legal representation until we have confirmed that a conflict of interest does not exist and we have expressly agreed in writing to the representation. Until there is such an agreement, we will not be deemed to have given you any advice, any information you send may not be deemed privileged and confidential, and we may be able to represent adverse parties.
Notice
Visiting, or interacting with, this website does not constitute an attorney-client relationship. Although we are always interested in hearing from visitors to our website, we cannot accept representation on a new matter from either existing clients or new clients until we know that we do not have a conflict of interest that would prevent us from doing so. Therefore, please do not send us any information about any new matter that may involve a potential legal representation until we have confirmed that a conflict of interest does not exist and we have expressly agreed in writing to the representation. Until there is such an agreement, we will not be deemed to have given you any advice, any information you send may not be deemed privileged and confidential, and we may be able to represent adverse parties.
Notice
Visiting, or interacting with, this website does not constitute an attorney-client relationship. Although we are always interested in hearing from visitors to our website, we cannot accept representation on a new matter from either existing clients or new clients until we know that we do not have a conflict of interest that would prevent us from doing so. Therefore, please do not send us any information about any new matter that may involve a potential legal representation until we have confirmed that a conflict of interest does not exist and we have expressly agreed in writing to the representation. Until there is such an agreement, we will not be deemed to have given you any advice, any information you send may not be deemed privileged and confidential, and we may be able to represent adverse parties.
Notice
Visiting, or interacting with, this website does not constitute an attorney-client relationship. Although we are always interested in hearing from visitors to our website, we cannot accept representation on a new matter from either existing clients or new clients until we know that we do not have a conflict of interest that would prevent us from doing so. Therefore, please do not send us any information about any new matter that may involve a potential legal representation until we have confirmed that a conflict of interest does not exist and we have expressly agreed in writing to the representation. Until there is such an agreement, we will not be deemed to have given you any advice, any information you send may not be deemed privileged and confidential, and we may be able to represent adverse parties.
Notice
Visiting, or interacting with, this website does not constitute an attorney-client relationship. Although we are always interested in hearing from visitors to our website, we cannot accept representation on a new matter from either existing clients or new clients until we know that we do not have a conflict of interest that would prevent us from doing so. Therefore, please do not send us any information about any new matter that may involve a potential legal representation until we have confirmed that a conflict of interest does not exist and we have expressly agreed in writing to the representation. Until there is such an agreement, we will not be deemed to have given you any advice, any information you send may not be deemed privileged and confidential, and we may be able to represent adverse parties.
Notice
Visiting, or interacting with, this website does not constitute an attorney-client relationship. Although we are always interested in hearing from visitors to our website, we cannot accept representation on a new matter from either existing clients or new clients until we know that we do not have a conflict of interest that would prevent us from doing so. Therefore, please do not send us any information about any new matter that may involve a potential legal representation until we have confirmed that a conflict of interest does not exist and we have expressly agreed in writing to the representation. Until there is such an agreement, we will not be deemed to have given you any advice, any information you send may not be deemed privileged and confidential, and we may be able to represent adverse parties.
Notice
Visiting, or interacting with, this website does not constitute an attorney-client relationship. Although we are always interested in hearing from visitors to our website, we cannot accept representation on a new matter from either existing clients or new clients until we know that we do not have a conflict of interest that would prevent us from doing so. Therefore, please do not send us any information about any new matter that may involve a potential legal representation until we have confirmed that a conflict of interest does not exist and we have expressly agreed in writing to the representation. Until there is such an agreement, we will not be deemed to have given you any advice, any information you send may not be deemed privileged and confidential, and we may be able to represent adverse parties.
Notice
Visiting, or interacting with, this website does not constitute an attorney-client relationship. Although we are always interested in hearing from visitors to our website, we cannot accept representation on a new matter from either existing clients or new clients until we know that we do not have a conflict of interest that would prevent us from doing so. Therefore, please do not send us any information about any new matter that may involve a potential legal representation until we have confirmed that a conflict of interest does not exist and we have expressly agreed in writing to the representation. Until there is such an agreement, we will not be deemed to have given you any advice, any information you send may not be deemed privileged and confidential, and we may be able to represent adverse parties.
Notice
Visiting, or interacting with, this website does not constitute an attorney-client relationship. Although we are always interested in hearing from visitors to our website, we cannot accept representation on a new matter from either existing clients or new clients until we know that we do not have a conflict of interest that would prevent us from doing so. Therefore, please do not send us any information about any new matter that may involve a potential legal representation until we have confirmed that a conflict of interest does not exist and we have expressly agreed in writing to the representation. Until there is such an agreement, we will not be deemed to have given you any advice, any information you send may not be deemed privileged and confidential, and we may be able to represent adverse parties.
Notice
Visiting, or interacting with, this website does not constitute an attorney-client relationship. Although we are always interested in hearing from visitors to our website, we cannot accept representation on a new matter from either existing clients or new clients until we know that we do not have a conflict of interest that would prevent us from doing so. Therefore, please do not send us any information about any new matter that may involve a potential legal representation until we have confirmed that a conflict of interest does not exist and we have expressly agreed in writing to the representation. Until there is such an agreement, we will not be deemed to have given you any advice, any information you send may not be deemed privileged and confidential, and we may be able to represent adverse parties.
Notice
Visiting, or interacting with, this website does not constitute an attorney-client relationship. Although we are always interested in hearing from visitors to our website, we cannot accept representation on a new matter from either existing clients or new clients until we know that we do not have a conflict of interest that would prevent us from doing so. Therefore, please do not send us any information about any new matter that may involve a potential legal representation until we have confirmed that a conflict of interest does not exist and we have expressly agreed in writing to the representation. Until there is such an agreement, we will not be deemed to have given you any advice, any information you send may not be deemed privileged and confidential, and we may be able to represent adverse parties.
Notice
Visiting, or interacting with, this website does not constitute an attorney-client relationship. Although we are always interested in hearing from visitors to our website, we cannot accept representation on a new matter from either existing clients or new clients until we know that we do not have a conflict of interest that would prevent us from doing so. Therefore, please do not send us any information about any new matter that may involve a potential legal representation until we have confirmed that a conflict of interest does not exist and we have expressly agreed in writing to the representation. Until there is such an agreement, we will not be deemed to have given you any advice, any information you send may not be deemed privileged and confidential, and we may be able to represent adverse parties.
Notice
Visiting, or interacting with, this website does not constitute an attorney-client relationship. Although we are always interested in hearing from visitors to our website, we cannot accept representation on a new matter from either existing clients or new clients until we know that we do not have a conflict of interest that would prevent us from doing so. Therefore, please do not send us any information about any new matter that may involve a potential legal representation until we have confirmed that a conflict of interest does not exist and we have expressly agreed in writing to the representation. Until there is such an agreement, we will not be deemed to have given you any advice, any information you send may not be deemed privileged and confidential, and we may be able to represent adverse parties.
Notice
Visiting, or interacting with, this website does not constitute an attorney-client relationship. Although we are always interested in hearing from visitors to our website, we cannot accept representation on a new matter from either existing clients or new clients until we know that we do not have a conflict of interest that would prevent us from doing so. Therefore, please do not send us any information about any new matter that may involve a potential legal representation until we have confirmed that a conflict of interest does not exist and we have expressly agreed in writing to the representation. Until there is such an agreement, we will not be deemed to have given you any advice, any information you send may not be deemed privileged and confidential, and we may be able to represent adverse parties.
Notice
Visiting, or interacting with, this website does not constitute an attorney-client relationship. Although we are always interested in hearing from visitors to our website, we cannot accept representation on a new matter from either existing clients or new clients until we know that we do not have a conflict of interest that would prevent us from doing so. Therefore, please do not send us any information about any new matter that may involve a potential legal representation until we have confirmed that a conflict of interest does not exist and we have expressly agreed in writing to the representation. Until there is such an agreement, we will not be deemed to have given you any advice, any information you send may not be deemed privileged and confidential, and we may be able to represent adverse parties.
Notice
Visiting, or interacting with, this website does not constitute an attorney-client relationship. Although we are always interested in hearing from visitors to our website, we cannot accept representation on a new matter from either existing clients or new clients until we know that we do not have a conflict of interest that would prevent us from doing so. Therefore, please do not send us any information about any new matter that may involve a potential legal representation until we have confirmed that a conflict of interest does not exist and we have expressly agreed in writing to the representation. Until there is such an agreement, we will not be deemed to have given you any advice, any information you send may not be deemed privileged and confidential, and we may be able to represent adverse parties.
Notice
Visiting, or interacting with, this website does not constitute an attorney-client relationship. Although we are always interested in hearing from visitors to our website, we cannot accept representation on a new matter from either existing clients or new clients until we know that we do not have a conflict of interest that would prevent us from doing so. Therefore, please do not send us any information about any new matter that may involve a potential legal representation until we have confirmed that a conflict of interest does not exist and we have expressly agreed in writing to the representation. Until there is such an agreement, we will not be deemed to have given you any advice, any information you send may not be deemed privileged and confidential, and we may be able to represent adverse parties.
Notice
Visiting, or interacting with, this website does not constitute an attorney-client relationship. Although we are always interested in hearing from visitors to our website, we cannot accept representation on a new matter from either existing clients or new clients until we know that we do not have a conflict of interest that would prevent us from doing so. Therefore, please do not send us any information about any new matter that may involve a potential legal representation until we have confirmed that a conflict of interest does not exist and we have expressly agreed in writing to the representation. Until there is such an agreement, we will not be deemed to have given you any advice, any information you send may not be deemed privileged and confidential, and we may be able to represent adverse parties.
Notice
Visiting, or interacting with, this website does not constitute an attorney-client relationship. Although we are always interested in hearing from visitors to our website, we cannot accept representation on a new matter from either existing clients or new clients until we know that we do not have a conflict of interest that would prevent us from doing so. Therefore, please do not send us any information about any new matter that may involve a potential legal representation until we have confirmed that a conflict of interest does not exist and we have expressly agreed in writing to the representation. Until there is such an agreement, we will not be deemed to have given you any advice, any information you send may not be deemed privileged and confidential, and we may be able to represent adverse parties.
Professionals
Name | Phone | |
---|---|---|
Theresa A. Androff Senior Litigation Attorney |
(615) 742-7933 | Theresa.Androff@bassberry.com |
Nicholas M. Bessette Associate |
(615) 742-7838 | nicholas.bessette@bassberry.com |
Richard Eiler Member |
(615) 742-7718 | reiler@bassberry.com |
David R. Esquivel Pro Bono Member |
(615) 742-6285 | desquivel@bassberry.com |
Lindsey Brown Fetzer Member |
(202) 827-2964 | lfetzer@bassberry.com |
Jeff H. Gibson Member |
(615) 742-7749 | jgibson@bassberry.com |
Angela Humphreys Member |
(615) 742-7852 | ahumphreys@bassberry.com |
Brian R. Iverson Member |
(202) 827-2954 | biverson@bassberry.com |
Wesley McCulloch Associate |
(615) 742-7822 | wesley.mcculloch@bassberry.com |
Sara K. Morgan Associate |
(615) 742-7740 | sara.morgan@bassberry.com |
Dawn Perez-Slavinski Member |
(202) 827-7973 | dawn.perez-slavinski@bassberry.com |
Lisa S. Rivera Member |
(615) 742-7707 | lrivera@bassberry.com |
Molly K. Ruberg Member |
(615) 742-7862 | mruberg@bassberry.com |
Angelique M. Salib Associate |
(202) 827-7978 | angelique.salib@bassberry.com |
Julia Tamulis Member |
(202) 827-2999 | jtamulis@bassberry.com |
T. Stephen C. Taylor Member |
(615) 742-7758 | staylor@bassberry.com |
Ryan D. Thomas Member |
(615) 742-7765 | rthomas@bassberry.com |
Meredith Mallard Thompson Counsel |
(615) 742-7759 | mthompson@bassberry.com |
Nesrin Garan Tift Member |
(615) 742-7861 | ntift@bassberry.com |
Price W. Wilson Member |
(615) 742-7820 | pwilson@bassberry.com |
Roy Wyman Member |
(615) 742-6220 | roy.wyman@bassberry.com |
Virginia Maynard Yetter Senior Litigation Attorney |
(615) 742-7858 | vyetter@bassberry.com |
Publications
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October 21, 2024 | Firm Publication
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September 18, 2024 | Firm Publication
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July 16, 2024 | Firm Publication
Past Events
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September 19, 2024 | Nashville, TennesseeBass, Berry & Sims
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May 2-3, 2024 | Chicago, IllinoisAmerican Conference Institute
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April 25, 2024 | WebinarBass, Berry & Sims
Media Mentions & Firm News
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August 16, 2024 | HealthLeaders
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April 23, 2024 | Modern Healthcare
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March 26, 2024 | AIS Health - Radar on Medicare Advantage
Publications
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October 21, 2024 | Firm Publication
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September 18, 2024 | Firm Publication
-
July 16, 2024 | Firm Publication
Past Events
-
September 19, 2024 | Nashville, TennesseeBass, Berry & Sims
-
May 2-3, 2024 | Chicago, IllinoisAmerican Conference Institute
-
April 25, 2024 | WebinarBass, Berry & Sims
Media Mentions & Firm News
-
August 16, 2024 | HealthLeaders
-
April 23, 2024 | Modern Healthcare
-
March 26, 2024 | AIS Health - Radar on Medicare Advantage
Contact
Notice
Visiting, or interacting with, this website does not constitute an attorney-client relationship. Although we are always interested in hearing from visitors to our website, we cannot accept representation on a new matter from either existing clients or new clients until we know that we do not have a conflict of interest that would prevent us from doing so. Therefore, please do not send us any information about any new matter that may involve a potential legal representation until we have confirmed that a conflict of interest does not exist and we have expressly agreed in writing to the representation. Until there is such an agreement, we will not be deemed to have given you any advice, any information you send may not be deemed privileged and confidential, and we may be able to represent adverse parties.
Notice
Visiting, or interacting with, this website does not constitute an attorney-client relationship. Although we are always interested in hearing from visitors to our website, we cannot accept representation on a new matter from either existing clients or new clients until we know that we do not have a conflict of interest that would prevent us from doing so. Therefore, please do not send us any information about any new matter that may involve a potential legal representation until we have confirmed that a conflict of interest does not exist and we have expressly agreed in writing to the representation. Until there is such an agreement, we will not be deemed to have given you any advice, any information you send may not be deemed privileged and confidential, and we may be able to represent adverse parties.
"Provides extensive skill in fraud and abuse matters such as Stark Law and Anti-Kickback Statute concerns. Regularly counsels a broad range of clients including manufacturers, pharmaceuticals, hospitals and health systems. Experience spans internal investigations, litigation and compliance issues related to Medicare." Client feedback: "It's an exceptional firm. They are responsive, knowledgeable and strategic in their thinking." "The Bass Berry team has an incredible ability to handle very complex matters. The team has excellent communication skills and is responsive." "Bass Berry's attorneys are strategic in their thinking, extremely collaborative and they get results."
From Chambers USA 2024