Susan Banks
Partner
Overview
Susan Banks is a healthcare attorney in Holland & Knight's Denver office. Ms. Banks focuses her national practice on advising hospitals, health systems and other healthcare providers and suppliers on the full range of Medicare and Medicaid compliance and reimbursement issues. She also helps clients navigate the complexities of healthcare delivery reform and inevitable operational challenges amid the ever-evolving regulatory environment.
A core part of Ms. Banks' practice involves counseling clients around potential federal healthcare program overpayments. Her skill set includes analysis of conditions of payment, risk assessments, design and oversight of internal investigations of compliance and reimbursement matters, coordination of payment audits and, when needed, development of self-disclosure and voluntary refund strategies. Clients appreciate her organized and down-to-earth approach to evaluating potential overpayments and mitigating risk. Ms. Banks' versatile, practical and business-oriented strategies help clients resolve potential exposure collaboratively and proactively.
Ms. Banks is deeply knowledgeable about Medicare and Medicaid reimbursement and funding mechanisms. She has extensive experience with payment requirements and policies under the various prospective payment systems and fee schedules, associated coverage policies and billing rules for various items and services, including such areas as nonphysician practitioner collaboration, Medicare cost-reporting considerations, hospital inpatient and outpatient billing requirements and beneficiary cost-sharing considerations. Ms. Banks' in-depth understanding of federal healthcare program design and payment streams makes her a strong strategist, issue spotter and problem solver when thinking through complex financial models and funding landscapes.
In addition, Ms. Banks has experience advising and representing clients in government investigations and civil and criminal litigation involving allegations of fraud and abuse arising under the federal False Claims Act (FCA) and federal Physician Self-Referral Law (Stark Law), as well as the federal Anti-Kickback Statute (AKS) and state law analogues. She has represented clients in connection with investigations and audits undertaken by federal and state regulatory and enforcement agencies, including the U.S. Department of Justice (DOJ), U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), Centers for Medicare & Medicaid Services (CMS) and its various program integrity contractors, and Health Resources and Services Administration (HRSA).
Ms. Banks also represents providers in challenging adverse final determinations before the Provider Reimbursement Review Board (PRRB) and other administrative bodies. She participates in administrative hearings on reimbursement disputes with state and federal agencies and, when more is needed, helps clients pursue judicial remedies through administrative litigation proceedings in court.
In addition to her legal practice, Ms. Banks has served as an adjunct faculty member at the University of Virginia School of Law, teaching a Medicare Practice Seminar and Medicare Coverage, Payment and Compliance course between 2017 and 2020.
Representative Experience
- Counseling of hospital and health system clients regarding compliance best practices, potential liabilities, risks and possible refund obligations pertaining to federal healthcare program rules and requirements, including by way of example, analysis, audits and advocacy in connection with:
- agency's erroneous application of Medicare's 3-Day Payment Window policy to patient transfers between system hospitals operated as unincorporated divisions of a single parent entity
- utilization of hospital-based advanced practice practitioners and potential fraud and abuse considerations related to global surgical package reimbursement
- concurrent and overlapping surgeries and potential hospital liabilities related to same
- restructuring of joint venture agreements governing management, operations and finances at a hospital's provider-based joint venture radiation oncology department
- provider-based compliance at hospital on- and off-campus outpatient departments, with assessment of reimbursement implications and notification to the Centers for Medicare & Medicaid Services (CMS) Regional Office and/or the Medical Administrative Contractor (MAC)
- Complex, multihospital internal investigation involving a health system's graduate medical education (GME) program, including assessment of residents' training activities, employment arrangements, immigration status, hospital privileging, payer credentialing and enrollment status, and related hospital and professional reimbursements to evaluate and resolve potential overpayment concerns and related federal healthcare program compliance considerations
- Design and oversight of a retrospective overpayment self-audit and voluntary refund involving review of historic short-stay hospital inpatient admissions to assess medical necessity and documentation of admitting physician's reasonable medical judgment that patients would require hospital care spanning two midnights
- Development and structuring of a clinical co-management arrangement between hospital and specialist physician groups to ensure meaningful collaboration, care coordination and achievement of quality improvement goals in a Center of Excellence model
- Healthcare regulatory diligence for acquisitions of U.S.-based and international medical device manufacturers, distributors and durable medical equipment suppliers, including small and large, asset and stock deals
- Administrative litigation in federal district court challenging an arbitrary and capricious subregulatory Medicare graduate medical education (GME) payment policy under the Administrative Procedure Act (APA) and the Medicare statute's notice-and-comment rulemaking requirements
- Administrative litigation before the Georgia Office of State Administrative Hearings (OSAH) over entitlement to Georgia Medicaid reimbursement for prescription drug claims involving a dispute over the sufficiency of the provider's electronic prescription record, successfully overturning the agency's adverse audit findings to forestall the planned revocation of $500,000 in a test-case with company-wide implications
- Administrative litigation before the Provider Reimbursement Review Board (PRRB) on behalf of multiple hospitals regarding a MAC's erroneous interpretations of Medicare payment policies and incorrect reimbursement determinations
Credentials
- University of Virginia School of Law, J.D.
- Northwestern University, B.A., Evolutionary Biology
- Colorado
- District of Columbia
- Virginia
- U.S. Court of Appeals for the District of Columbia Circuit
- U.S. District Court for the District of Columbia
- District of Columbia Court of Appeals
- Supreme Court of Virginia
- Colorado Supreme Court
- American Health Law Association (AHLA)
- Virginia Journal of International Law, Editorial Board Member, University of Virginia Law School, 2007-2009
- Rising Stars, Colorado Super Lawyers magazine, Health Care, Administrative Law, 2016-2018, 2020
- Thomas Marshall Miller Prize, University of Virginia School of Law, May 2009
- Hardy Cross Dillard Fellowship of Legal Research and Writing, University of Virginia School of Law, 2007-2008 and 2008-2009