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The Best Lawyers in America© is the longest-running, peer-review publication in the legal profession.  Every year, Best Lawyers conducts comprehensive surveys of tens of thousands of lawyers who confidentially evaluate their professional peers.  Based on the results of these surveys, the publication designates the year’s leading lawyers in all 50 states and the District of Columbia.

The Milligan Lawless attorneys recognized in the 2021 edition are:

2021 Best Lawyers

  • Bryan S. Bailey: Health Care Law
  • John A. Conley: Administrative/Regulatory Law
  • Robert J. Itri: Commercial Litigation; Copyright Law; Litigation – Intellectual Property; and Trademark Law
  • Steven T. Lawrence: Corporate Law
  • Thomas A. Maraz: Construction Law
  • Robert J. Milligan: Health Care Law
  • James R. Taylor: Health Care Law


2021 Best Lawyers: Ones To Watch

  • Lauren A. Crawford: Commercial Litigation
  • Kylie E. Mote: Health Care Law
  • Miranda Preston: Health Care Law
By Steven T. Lawrence, Esq. and Miranda Preston, Esq. Milligan Lawless, P.C

Part 1 of this series explained the changed landscape of M&A due to the COVID-19 pandemic, and discussed five areas where the pandemic has affected the terms of M&A transactions.  In this segment, we will discuss practical considerations for entities who are contemplating a sale, whether during or after the pandemic.

  1. Attend to the Details.  The operations of many healthcare practices impacted by the pandemic have rightly turned to focus on the delivery services.  But, now is the time to make sure that the details of business are in order.  As compliance is frequently a starting place for buyers, sellers should thoroughly review the company’s compliance efforts and systems, and update such compliance programs as needed.  Intellectual property is sometimes an afterthought, but the pandemic may present unique opportunities for the pursuit of intellectual property protection or the development of new intellectual property.  This is also a good time to ensure that corporate formalities are observed and the company’s books and records are in order.  Prospective sellers should examine their existing organization and operations and make adjustments as needed in an effort to be ready for sale.  Prioritizing the details of the business in advance of a sale pays dividends during the due diligence process.

  2. Consider CARES Act Relief.  From the outset of any potential transaction, sellers should consider the impact that the acquisition may have on any CARES Act[1] relief the seller has received or is seeking.  Buyers will be paying particular attention to these issues, and both parties should take care to structure any transaction in a way that does not inadvertently alter the seller’s eligibility status or violate any program requirements.[2]  There are a number of certifications borrowers must make during the application and forgiveness process, including certifications related to the use of funds, the borrower’s organizational structure, and the information provided to support the forgiveness application.  Inaccurate certifications are subject to criminal and civil fraud claims.  Sellers who have received PPP loans should consider how a potential transaction effects the Seller’s ability to participate in PPP loan forgiveness.  Sellers should thoroughly review their loan documents for provisions related to changes of ownership or control, which provisions are usually broadly defined.  Typically, the seller will need to obtain the consent of the lender before entering into any transaction that results in a change of control.

  3. Be Creative.  Many businesses that have been successful in the pandemic have pivoted using existing products or service offerings in a new way.  From an M&A perspective, those new lines of business may become spin-off candidates and the source of joint ventures in the future.  Buyers will be looking for sellers that are creative and have sought new markets even in the face of the pandemic.

  4. Ready Your Team.  The pandemic has unfortunately seen a massive loss of employment.  While the rate of unemployment claims is slowing, there are still significant opportunities to bring on new talent to your organization to lead the way in the post-pandemic landscape.  Sellers should retain knowledgeable consultants and advisors, such as legal counsel and accounts.

The COVID-19 pandemic has dramatically changed the M&A market.  However, the pandemic also presents an opportunity for prospective sellers to improve their position for a future M&A sale.  If you have any questions regarding any M&A issues, the business transactions team at Milligan Lawless is here to assist.  Please contact Steve Lawrence at 602-792-3635 or steve@milliganlawless.com or Miranda Preston at 602-792-3511 or miranda@milliganlawless.com.


[1] The Coronavirus Aid, Relief, and Economic Security Act (the “CARES Act”) was enacted on March 27, 2020 and created the Paycheck Protection Program (“PPP”), a forgivable small business loan program; and authorized additional funding for the Small Business Administration (SBA) Economic Injury Disaster Loan (EIDL) program, among other features.

[2]  Additional information from Milligan Lawless on the CARES Act and PPP is available here: The CARES Act – Paycheck Protection Program Loan (Mar. 28, 2020); Paycheck Protection Program Loan Forgiveness (Mar. 29, 2020); Update on CARES Act: SBA Implements Interim Final Rule for Paycheck Protection Program Loans (Apr. 3, 2020); CARES Act Provider Relief Fund Distributions (Apr. 14, 2020); Update on CARES Act Provider Relief Fund General Distributions (Apr. 30, 2020); and Congress Passes Favorable Amendments to the Payroll Protection Program (Jun. 5, 2020).


By Steven T. Lawrence, Esq. and Miranda Preston, Esq.
Milligan Lawless, P.C

The COVID-19 pandemic has impacted all aspects of business in the United States, M&A transactions in particular.   The global IPO market ground to a halt in March of 2020, and corresponding developments in the M&A market were felt almost immediately.[1]  By the end of March 2020, M&A levels for the first quarter of 2020 had fallen by more than 50% compared to levels for the first quarter of 2019.[2]  Many companies and private equity buyers moved away from the deal market in an effort to preserve jobs, customers and resources.  For example, Xerox ceased its $35 billion takeover bid for HP, SoftBank terminated a $3 billion tender offer for WeWork stock and Hexcel and Woodward ceased discussions on a $6.4 billion merger of equals.[3] 

Private company transactions were also impacted – a recent study of private company deals valued at less than $2 million found that 46% of deals were delayed and 11% were cancelled as a result of the pandemic.[4]  Some transactions involving the acquisition of physician practices that primarily perform elective procedures were delayed or cancelled altogether following the suspension of the performance of elective procedures.  The pandemic caused the re-evaluation of the terms of M&A transactions.  Transactions are still occurring, but in many cases the pandemic has caused the parties to agree to modified terms and conditions.  This article highlights five areas where the pandemic has affected the terms of M&A transactions. The second part of this two-part series will discuss actions prospective sellers can take in the face of the pandemic to optimize their position as targets for acquisition.

  1. Purchase Price.  One of the most noticeable effects of the pandemic has been the reassessment of target company valuations.  M&A transactions in 2020 have seen a greater prevalence of contingent forms of consideration, such as earn-outs or increased percentages of escrowed purchase price.  In the health care context, earn-outs and other post-closing adjustments can have regulatory implications.[5]  These contingencies add complexity to the transaction and increase the potential for disputes between the buyer and seller.  Post-closing adjustments have a new level of importance as day-to-day uncertainties of operations have made the ability to anticipate performance more difficult.

  2. Due DiligenceWhile the diligence effort is always an important aspect of any transaction, the pandemic has caused a heightened emphasis on the buyer’s diligence of the seller.  Buyers are now taking an even deeper dive into the pandemic’s impact on the target company’s sales, regulatory compliance, contract obligations, internal controls, among many other aspects.  A significant portion of due diligence occurs electronically over remote technologies, but not everything can be done virtually (e.g. site visits, surveys).  As in-person diligence remains limited, sellers should expect a longer and more rigorous due diligence process.

  3. Representations and Warranties.  There has already been a shift in the negotiations of representations and warranties to address COVID-19.  Some buyers are now requiring that sellers represent and warrant regarding: (1) the seller’s compliance with all local laws, rules and regulations regarding the pandemic, including any restrictions regarding the opening and closing of businesses; (2) the impact of the pandemic on the seller’s workforce and the ability of the seller to continue to operate in the face of “shut-down” orders; (3) whether the seller has obtained any CARES Act related relief, the seller’s eligibility for relief, and the seller’s compliance with CARES Act program requirements; and (4) the internal controls, policies and procedures of the seller regarding a safe workplace, including compliance with U.S. Centers for Disease Control guidance regarding re-opening.  Given the depth of these new representations and warranties, representations and warranties insurance (“RWI”) has become a consideration for many sellers who would have not previously considered it, or who may have determined the cost of RWI premiums outweighed its benefits.  This has led to new negotiations between sellers and insurers over the terms of such insurance and whether the policy contains COVID-19-related exclusions (which may result in coverage gaps during the pandemic).

  4. Operating CovenantsBuyers are demanding tighter controls on the target company between the signing of a purchase agreement and the closing of the transaction.  This tighter control is typically evidenced by covenants that obligate the selling company to operate in a certain way or with certain limitations, typically based on the “ordinary course” of the business.  Operating a business “in the ordinary course” may not be applicable (or as applicable) in a time of a worldwide pandemic.  What is the “ordinary course” today?  Does “ordinary course” mean pre-pandemic?  Historically, these provisions have been somewhat loose and allowed the selling company a level of room to continue to operate the business as it had historically operated.  However, in the pandemic era, buyers are demanding much greater controls and tighter restrictions on the selling company’s pre-closing operations.

  5. Material Adverse Effect.  Material adverse change or Material Adverse Effect (“MAE”) clauses generally allow a buyer to walk away from the deal if the seller’s business and operations suffer a material adverse change between the signing of the purchase agreement the and closing of the  transaction.  For transactions that were entered into before the onset of the pandemic, or for those contracts of the selling company that are under review, a question may arise whether the pandemic constitutes a MAE.  The party invoking a MAE faces a high standard in demonstrating that there has been an adverse change to the selling company’s business that qualifies as a MAE that would excuse the buyer’s performance.[1]  In evaluating whether there has been a MAE, the courts will likely consider: (1) the express language of the agreement; (2) whether a pandemic or epidemic is an anticipated (or reasonably anticipated) event; and (3) the depth of the impact on the business and length and scope of the downturn.  Given the fact that the long-term effects of COVID-19 are still unknown, and the high standard for demonstrating a MAE, it will likely be difficult for buyers to successfully argue that the disruptions caused by the pandemic constitute a MAE.

The COVID-19 pandemic has wreaked havoc on the U.S. economy; the M&A market is not immune to the pandemic’s negative impact.  That said, some M&A activity has continued unabated, though the terms of such deals and the associated risks look markedly different than they did pre-pandemic.  For information about the steps that prospective sellers can take to better position themselves when the time comes for a sale, stay tuned for part two of this series.  If you have any questions regarding any M&A issues, the business transactions team at Milligan Lawless is here to assist.  Please contact Steve Lawrence at 602-792-3635 or steve@milliganlawless.com or Miranda Preston at 602-792-3511 or miranda@milliganlawless.com.


[1] Jens Kengelbach, Jeff Gell, Georg Keienburg, Dominik Degen and Daniel Kim, COVID-19’s Impact on Global M&A, Boston Consulting Group, March 26, 2020.

[2] Richard Harroch, The Impact of the Coronavirus on Mergers and Acquisitions, Forbes, April 17, 2020.

[3] Cara Lombardo, Xerox Is Ending Hostile Takeover Bid for HP, The Wall Street Journal, April 1, 2020; Peter Eavis, SoftBank Won’t Buy $3 Billion in WeWork Stock, New York Times, April 1, 2020; Reuters, Aero Suppliers Hexcel and Woodward Scrap Deal as Coronavirus Pummels Industry, April 6, 2020.

[4] Market Pulse Report, Pepperdine Graziadio Business School, April 29, 2020.

[5] For example, in the context of the sale of a physician practice, where a portion of the purchase price is paid as an earn-out, if the owners of the seller will refer any patients to the buyer post-closing, the Stark Law and the Anti-Kickback Statute may be implicated.

[6] See Akorn, Inc. v. Fresenius Kabi AG, No. CV 2018-0300-JTL, 2018 WL 4719347, at *53 (Del. Ch. Oct. 1, 2018), aff’d, 198 A.3d 724 (Del. 2018) (citing Hexion Specialty Chemicals, Inc. v. Huntsman Corp., 965 A.2d 715 (Del. Ch. 2008) at 738 (stating “A buyer faces a heavy burden when it attempts to invoke a material adverse effect clause in order to avoid its obligation to close”).

Written by: John A. Conley

On August 3, 2020, a federal court in New York state struck down portions of the regulations implementing the Families First Coronavirus Response Act (“FFCRA”).  In litigation brought by the state of New York against the United States Department of Labor (“DOL”), a U.S. District Court, among other things, substantially narrowed the “health care provider” exception to the FFCRA.

The FFCRA requires employers to provide employees paid leave benefits in connection with certain COVID-19-related absences.  The health care provider exception allows employers to deny FFCRA’s leave benefits to employee health care providers.  The court rejected as too broad DOL’s regulatory definition of “health care provider” which included:

“[A]nyone employed at any doctor’s office, hospital, health care center, clinic, post-secondary educational institution offering health care instruction, medical school, local health department or agency, nursing facility, retirement facility, nursing home, home health care provider, any facility that performs laboratory or medical testing, pharmacy, or any similar institution, Employer, or entity. This includes any permanent or temporary institution, facility, location, or site where medical services are provided that are similar to such institutions, as well as any individual employed by an entity that contracts with any of these institution . . . .”

DOL Final Rule at 19,351 (§ 826.25).  Instead, after recognizing its applicability to the FFCRA, the court applied the narrower Family Medical Leave Act “health care provider” definition:

“(A) a doctor of medicine or osteopathy who is authorized to practice medicine or surgery (as appropriate) by the State in which the doctor practices; or (B) any other person determined by the Secretary to be capable of providing health care services.”

29 U.S.C. § 2611(6); State of New York v. U.S. Department of Labor, et al., No. 1:20-cv-03020 (S.D. N.Y. Aug. 3, 2020).

In that same decision, the court also: rejected a DOL rule which denied FFRCA leave to employees in the absence of available work for the employee to perform (e.g. during a furlough); vacated a DOL rule requiring employer consent to intermittent use of FFCRA leave; and struck down a DOL requirement that employees provide FFCRA documentation in advance of taking leave.

The court’s decision substantially affects key components of the FFCRA.  Significantly, for healthcare sector employers, it may reduce the ability to exempt most employees from FFCRA leave benefits.  It also raises the question of potential liability for employers who denied employees FFCRA leave based upon DOL’s now-vacated regulations.  Finally, the impact of the court’s decision outside the state of New York is currently unclear.  Employers are encouraged to speak with an attorney if they have questions about FFCRA compliance or other employee leave-related matters.

For more information regarding the implications of the court’s decision, the FFCRA or other employment-related matters, please contact attorney John Conley at (602) 792-3500.

Written by: Chelsea Gulinson

On June 2, 2020, the Centers for Medicare and Medicaid Services (CMS) published updated FAQs related to Medicare Fee-for-Service Billing and COVID-19, and the interim final rule with comment period (IFC), CMS-1744-IFC.  These updates supplement CMS’ FAQs on Section 1135 Waivers, released March 15, 2019. 

In these FAQs, CMS analyzes provisions from the Coronavirus Aid, Relief, and Economic Security (CARES) Act relevant to payment for COVID-19 testing, billing, diagnostic services, hospital services, rural health clinics, opioid treatment programs, drugs, and vaccines, among other topics. 

Of particular interest to physicians are the following FAQs and a brief summary of CMS’ response:

  • What does the IFC change for physician and practitioner billing?

The IFC makes temporary changes to certain policies, such as supervision by a physician or non-physician practitioner (NPP), payment for certain services furnished by teaching physicians and moonlighting residents, telehealth, services furnished by Rural Health Clinics and Federally Qualified Health Centers, and payments to labs for specimen collection.

  • What are the changes to supervision?

CMS has revised the definition of “direct supervision” and changed the supervision requirements for hospital outpatient non-surgical extended duration therapeutic services from direct supervision to general supervision.

  • When do the changes on supervision take effect and for how long?

The supervision changes are effective March 1, 2020 and last for the duration of the national COVID-19 Public Health Emergency (PHE).

  • Can residents furnish telehealth services?

Through the interim final rule and for the duration of the PHE, Medicare may pay for services billed by teaching physicians when residents furnish telehealth services to beneficiaries under direct supervision of a teaching physician provided by interactive telecommunications technology.

  • Does Medicare pay for a doctor or NPP to furnish care in a beneficiary’s home?

Yes.  Medicare pays for care furnished in a beneficiary’s home, including evaluation and management services, telehealth services, and non-face-to-face services to assess and manage a beneficiary’s condition.  In addition, Medicare pays physicians for services furnished in a beneficiary’s home by auxiliary personnel, as long as those services are furnished incident to a physician’s service and with the physician’s appropriate supervision.

  • Can a “distant site practitioner” furnish Medicare telehealth services from their home?  Or do they have to be in a medical facility?

There are no payment restrictions on distant site practitioners furnishing Medicare telehealth services from their home during the PHE.

  • The ambulatory surgical center (ASC) in my community has recently converted to a hospital under unique provisions available during the PHE and my medical group has been contracted to provide care there.  If clinicians from our medical group furnish covered professional services to Medicare beneficiaries at the ASC-turned-Hospital, can we bill Medicare for non-surgical services?

Yes.  Practitioners are permitted to bill under Medicare can bill Medicare for covered professional hospital services furnished to beneficiaries at an ASC-turned-Hospital during the PHE.

  • My medical group is contracted to provide care at a local hospital.  The hospital has built a tent, transitioned a gymnasium, or converted another non-clinical location into a space to provide patient care.  If clinicians from our medical group furnish covered professional services to Medicare beneficiaries at those new patient care locations, can we bill Medicare?

Yes.  Practitioners who bill under Medicare may bill Medicare for covered professional services furnished to patients at temporary expansion sites, such as gymnasiums or other non-clinical locations.

  • The state, Army Corps of Engineers, or other governmental entity established a new care location in our area by repurposing and retrofitting a convention center, gymnasium, or other site for patient care.  My medical group has been asked to provide patient care in one of these locations.  Can we bill Medicare for covered professional services furnished in these locations?  If so, are there reporting or billing rules that determine how this is done?

Yes.  Practitioners who bill under Medicare may bill Medicare for covered professional services furnished to patients at temporary expansion sites, including those established by the state, Army Corps of Engineers, or other governmental entities.  To bill for these services, practitioners would bill under the Medicare Physician Fee Schedule and follow existing billing rules for services provided in hospitals.  Practitioners should also add the “CR” modifier to professional claims for care provided in temporary expansion sites.

For full answers to these physician-related and other FAQs, please visit this website: https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf.  For any other questions or comments, please contact Milligan Lawless at 602-792-3500.

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