Clients include:
- Academic medical centers
- Ambulatory surgical centers
- Ambulance suppliers
- Billing and reimbursement consultants
- Clinical laboratories
- DMEPOS suppliers
- Electronic health records companies
- Federally Qualified Health Centers
- Franchised health care businesses
- Health care technology developers
- Home health agencies
- Hospitals
- Imaging centers
- Pharmacies
- Physicians and non-physician practitioners
- Physician group practices
- Research organizations
- Skilled nursing facilities
- Substance use disorder treatment providers
- Third party administrators
- Utilization management companies
Compliance and Reimbursement
Jesse’s counsel covers a wide range of services and compliance requirements. He has deep experience in advising Part A providers and Part B suppliers on complex billing and reimbursement issues, enrollment and participation and program integrity matters.
Examples include the following:
- Physician and non-physician billing, such as incident-to, split shared, billing for teaching physician services and addressing GME requirements.
- Specialty and ancillary services reimbursement (e.g., anesthesia, freestanding and provider-based diagnostic/therapeutic billing and supervision, global surgery package, mental health, etc.).
- Complex payment systems, such as hospital prospective payment (e.g., outpatient unbundling, 72-hour rule), 340B drug program, cost reporting, transplant reimbursement and clinical lab/ PAMA, “shell” lab rule; similar guidance for other PPS providers (HHA, SNF, etc.).
- Assisting providers/suppliers to comply with conditions of participation/coverage, such as DMEPOS and IDTF standards, ASC conditions for coverage, hospital and hospice conditions of participation and CLIA matters; Jesse has also advised on various accreditation standards.
- Regulatory matters associated with provider development of joint ventures, such as cost reporting issues associated with hospital-owning subsidiary suppliers and compliance with provider-based regulations for co-located hospital/physician arrangements.
- CMS initiatives, such as the Quality Payment Program’s MIPS and APM pathways and various CMMI demonstration projects.
- Medicare/Medicaid enrollment and revalidation issues, such as advising on complex CMS-855 questions and addressing Medicaid waiver (e.g., home and community-based services) programs.
- Self-disclosure options, such as OIG’s Self-Disclosure Protocol and CMS Self-Referral Disclosure Protocol, 60-day overpayment regulation and various other issues associated with conditions of payment and refunds (such as Medicaid and commercial payor refunds).
Stark Law, Anti-kickback Statute and Other Fraud and Abuse
As a seasoned health care attorney, Jesse provides comprehensive counsel on the Stark Law, Anti-kickback Statute and similar federal and state fraud and abuse laws, including the Civil Monetary Penalties Law, EKRA, the Anti-Markup Rule and a diverse array of state-specific fee splitting, patient brokering and related restrictions.
Examples of his work include advising on health care system/physician relationships, structuring physician compensation arrangements, both for group practices and tax-exempt organizations, counseling on issues of fair market value and commercial reasonableness and structuring bonus pools, incentive programs, outcomes-based compensation, productivity-driven arrangements and shared savings arrangements. He also advises providers on structuring patient incentive programs that comply with beneficiary inducement prohibitions. With experience in state-specific self-referral, fee-splitting and anti-kickback laws, particularly for franchised healthcare businesses operating nationally, he offers critical insights into multi-jurisdictional compliance.
Antitrust
Jesse counsels clients on compliance with antitrust laws, including issues that can arise in the context of negotiating payor agreements, analyzing competitive impacts of transactions on relevant product and geographic markets, advising on pre-consummation information exchange and Hart Scott Rodino matters and counseling on issues of clinical and financial integration between competitors and collaborating within Accountable Care Organizations and other outcomes-based models in a manner that complies with antitrust guidelines.
Before joining the firm, Jesse served as assistant attorney general in the Health Care and Antitrust Division of the Minnesota Attorney General’s Office, where he focused on regulatory enforcement and provided legal counsel to state agencies, including the Minnesota Department of Health.
Litigation Support, Investigations and Negotiations
Experienced in litigation and investigations related to alleged regulatory violations across the healthcare sector, Jesse regularly advises clients on complex cases. Examples of his work include advising physician owners alleged to have improperly allocated profit shares and productivity bonuses in violation of Stark Law group practice payment regulations, clinical labs facing allegations of non-compliance with CLIA proficiency testing regulations, ASCs defending compensation structures under the Anti-Kickback Statute and False Claims Act, hospitals involved in disputes over whether physician compensation is consistent with fair market value and did not take into account the volume or value of referrals, working with hospitals and physician groups on compliance with billing rules in the areas of outpatient unbundling, transplant services and cost reporting and leasing arrangements that allegedly involved per-click or percentage-based payment terms.
Mergers and Acquisitions
Jesse further offers legal support in structuring physician compensation for group practices and nonprofit organizations, advising on fair market value and structuring collaborations, joint ventures and other financial arrangements to maximize the likelihood of business success while complying with regulatory guidelines. He has considerable experience working with valuation firms in developing and negotiating health care transactions. He also aids health care organizations in understanding and addressing potential antitrust risks associated with mergers and various forms of joint ventures.
In addition, Jesse supports clients with the negotiations of and document drafting related to a wide range of transactions, including equity and contractual joint ventures, specialty service line agreements (e.g., oncology, transplant and cardiovascular), professional service agreements and coverage agreements, management and co-management arrangements, under arrangement contracts, purchased test arrangements, gainsharing or shared savings programs, recruitment agreements, equipment and space leases, EHR arrangements, data use agreements and research contracts.
Privacy and Security Compliance
Jesse offers strategic guidance on federal and state privacy compliance, including HIPAA, FERPA, Part 2 Substance Use Disorder, the Common Rule and diverse state privacy regulations. Notable experience includes developing the “Foundations in Privacy Toolkit” for the Minnesota Department of Health to help providers navigate intersecting and competing privacy laws. He advises covered entities and business associates on HIPAA Security and Privacy Rule compliance, from risk assessment to managing multi-state breach responses. He is skilled in nuanced HIPAA topics, including hybrid entities, research data compliance, marketing and fundraising, limited data sets and de-identification.
