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Jim Gjerset is a founding partner of Gjerset & Lorenz, LLP. Mr. Gjerset began his career with the Texas Office of the Attorney General where, as Assistant Attorney General, he represented the state in civil litigation involving health care fraud and abuse and unfair insurance practices. Mr. Gjerset also represented the state in a lawsuit against the federal government for its failure to reimburse states for the cost of health care provided to indigent illegal immigrants.
In 1998, Mr. Gjerset and Ms. Shauna Lorenz formed the now national health care law firm of Gjerset & Lorenz, LLP in Austin, Texas. Mr. Gjerset has continued his health care industry practice and has extensive experience representing a wide spectrum of the industry including institutional providers, individual providers, commercial payors, governmental payors, management services organizations and suppliers. Mr. Gjerset's practice is presently focused on the provider side of the industry, and he routinely advises clients on complex governmental reimbursement issues, diverse business transactions, day-to-day operational issues, and regulatory compliance including licensure, certification, reimbursement, antitrust, fraud and abuse, cost reporting, government contract negotiation, preparing for, responding to, and defending against state and federal government investigations and administrative penalty actions.
Mr. Gjerset also has extensive experience in the commercial insurance arena including negotiating managed care contracts for hospitals and physician groups; advising on the licensure and regulation of insurance companies, HMOs, third-party administrators, utilization review agents, and insurance agents; forming integrated delivery systems, physician hospital organizations, captive insurance agencies, independent practice associations, management service organizations, limited liability companies, and federally qualified health centers
Representative Experience
Successful defense of a state recoupment effort alleging overpayment of an aggregate $30 million from over 25 providers due to the inclusion of alleged unallowable costs;
Successful defense of over 100 license revocation, decertification and administrative penalty actions by state and federal regulatory agencies;
Developed policies, procedures and plans of action for the closure of numerous acute care hospitals, psychiatric hospitals, rehabilitation hospitals and ancillary services providers;
Led the divestiture of a national home health division to numerous institutional and individual purchasers;
Successfully recouped over $20 million in withheld Medicaid and tobacco pool funding for four psychiatric hospitals for whom the State argued had exceeded their hospital specific limits;
Successful defense of individual owners from personal liability for over $5 million in governmental overpayments due upon cost report reconciliation;
Developed and implemented systems to ensure state and federal agencies accurately included all services provided when calculating compensation related to Medicaid Disproportionate Share Hospital funding and Upper Payment Limit funding for hospitals and hospital systems in numerous states including Alaska, California, Nevada, Arizona, New Mexico, Texas, Missouri, Louisiana, Pennsylvania, Florida and the District of Columbia;
Developed local Upper Payment Limit (UPL) programs for two public hospitals that generate over $15 million per year in federal matching dollars;
Performed legal and reimbursement due diligence for multi-hospital system acquisitions including the development of models to realign the hospitals to maximize government program reimbursement;
Successfully defended a psychiatric hospital system from exclusion of five of its hospitals from the Medicare and Medicaid programs, licensure revocation and civil penalties following several suicides and abuse and neglect findings;
Numerous analyses of the financial implications, regulatory issues and operational steps of consolidating hospitals under a single license and provider number and segregating previously combined campuses;
Developed the strategy and led the negotiation and litigation teams in actions against various state and commercial payors nationwide resulting in:
a $16 million global resolution of a dispute over the contractual provisions governing high cost pass through reimbursement;
an injunction against a state Medicaid program for 14 public and private hospitals for failing to include a category of allowable costs that resulted in the underpayment of over $15 million per year for a four-year period;
a $10 million settlement upon completion of the provider's case in chief in a case where the insurer had denied hundreds of claims arguing that the hospital was required to bundle items and when the insurer had refused to pay for claims delegated to a defunct IPA;
a $5.5 million final judgment against a large managed care company that underpaid hundreds of claims arguing the contract required daily level of care authorizations, refusal to comply with stop-loss provisions and down-coding;
a $4.5 million arbitration award against a Medicare+Choice plan for excluding non-allowable Medicare items from the contractual reimbursement;
a $4.3 million settlement of underpaid claims from a national insurer that argued its delegated IPAs were responsible for the claims;
a $3.8 million judgment plus interest and penalties against an IPA that removed line item charges prior to calculating payment for stop-loss claims;
a $3.1 million recovery against a state Medicaid program for inappropriate timely filing denials.
Professional Affiliations and Activities
President of the Travis County Bar Association's Health Law Section; Member: American Health Lawyers Association; Health Law and Administrative Law Sections of the State Bar of Texas; Administrative Law and Regulatory Practice Section of the American Bar Association; the Texas Hospital Association; the Administrative Law Section of the Travis County Bar Association
Vice-Chair of the Texas Department of Insurance Advisory Committee on unfair insurance practices
Chairman of the Brackenridge Hospital Oversight Council
Special Technical Advisor to the Texas Hospital Association's Medicaid Tax Force
Education and Professional Qualifications
American University, Washington College of Law, J.D., cum laude, 1992
Brown University, B. A., 1987.
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