Paul L. Garcia

Paul Garcia makes good on that promise, guiding providers and clinical laboratories through their highest-stakes reimbursement, litigation, and regulatory challenges. His strategic counsel is informed by firsthand experience developing policy within California’s Medicaid program (Medi-Cal), giving him a unique insider’s perspective on how government payors operate and where the law and business realities collide.

Paul’s clients, including hospital associations, hospital systems, and clinical laboratories, turn to him for his expertise on state Medicaid, Medicare, and audits and investigations. He provides actionable counsel on internal investigations of potential overpayments under the 60-Day Rule, develops compliance programs to protect clients from costly government scrutiny, and represents clients in litigation, particularly related to reimbursement disputes. His forward-looking guidance was critical during the COVID-19 pandemic and continues to help clients navigate the operational impact of significant new rulemaking from the Centers for Medicare & Medicaid Services (CMS).

Paul began his legal career with DHCS, the single-state agency that administers California’s Medicaid program (Medi-Cal). There, he provided legal counsel to develop and support Medi-Cal managed care financing and reimbursement policy, including DHCS’s implementation of the 2016 Medicaid Managed Care Final Rule as it relates to key reimbursement programs and state directed payment arrangements.

Previously, Paul served as an Executive Fellow through the prestigious Capital Fellows Program, where he worked with executive staff to implement state and federal health care reforms at Covered California. While in law school, Paul served as an extern for Hon. Kim McLane Wardlaw in the United States Court of Appeals for the Ninth Circuit.

Representative Matters

• Secured a landmark appellate victory in the in the U.S. Court of Appeals for the Eleventh Circuit for a Federally Qualified Health Center (FQHC) in a major Medicaid reimbursement dispute. This precedent-setting decision has significant implications for providers seeking to challenge state Medicaid agencies. Family Health Centers of Sw. Fla., Inc. v. Agency for Health Care Admin., 83 F.4th 1341 (11th Cir. 2023).
• Represents clinical laboratories in high-stakes litigation involving unpaid and underpaid COVID-19 claims under section 3202 of the federal CARES Act and related state laws.
• Negotiated settlement in 8-figure dispute with California’s Department of Health Care Services (DHCS) on behalf of major hospital system, resolving a complex multi-year dispute and preserving critical funding for patient services.
• Negotiated global settlement with Medicare Administrative Contractor on behalf of multiple clinical laboratories regarding 7-figure overpayment assessment related to laboratory panels.

Second-chaired a 5-day hearing involving 1002 pharmacy claims, securing a favorable decision regarding all but 14 claims.