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Practical and entertaining education for
attorneys, accountants, business owners
and executives, and investors.
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DISCLAIMER
The material in this webinar is for informational purposes only. It should not be
considered legal, financial or other professional advice. You should consult with an
attorney or other appropriate professional to determine what may be best for your
individual needs. While Financial Poise™ takes reasonable steps to ensure the information
it publishes is accurate, Financial Poise™ makes no guaranty in this regard.
About this PowerPoint: if you are looking at this PowerPoint without the benefit of
listening to the conversation that surrounded it then you are doing yourself a disservice.
This PowerPoint was prepared in contemplation of being viewed in conjunction with
listening to a one hour webinar on the topic
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Thank You To Our Sponsor
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MEET THE FACULTY
Moderator:
Thad Wilson – King & Spalding LLP
Panelists:
Marshall Glade – GlassRatner Advisory and Capital Group
Brian Bonaviri – Grant Thornton LLP
Andrew H. Sherman – Sills Cummis & Gross, P.C.
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ABOUT THIS WEBINAR:
Focus on Health Care
Chapter 11 cases involving healthcare providers involves issues that simply do not exist on
chapter 11s of other entities. First, public health and safety issues are at issue in a way that
generally is not the case with other debtors. There is, consequently, a large state and
federal non-bankruptcy law regulatory overlay in such cases to make sure that the care of
patients remains paramount. Also helping to effect this is that courts recognize the "duty of
obedience" owed by the leadership of a healthcare provider. As a practical matter, the
stakeholders with whom a healthcare provider debtor must consider, and deal with, are
often much broader than in other Chapter 11 cases. These are some of the issues this
webinar addresses.
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ABOUT THIS SERIES:
Chapter 11 – Special Issues
As of this writing (January 2019) many people (economists) with crystal balls (relevant
training, experience, and tools) predict that the economy is turning, and not for the
better. If correct, one likely result will be a significant uptick in the number of Chapter
11 bankruptcy cases filed by businesses across the American Landscape. Designed for
the corporate attorney, litigator, and anyone else who is not a Chapter 11 bankruptcy
expert who finds herself stepping into bankruptcy for the first time or only on occasion,
each episode in this Financial Poise webinar series takes a deep dive into one aspect of
a chapter 11 bankruptcy case at a level that can be understood by the non-expert.
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EPISODES IN THIS SERIES
4/17/19 Episode #1:
Focus on Retail
5/15/19 Episode #2:
Focus on Single Asset Real Estate
6/19/19 Episode #3:
Focus on Health Care
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All webinars will be available
On Demand approximately 4 weeks
after they premiere.
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Episode #3:
Focus on Health Care
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Health care business – “any public or private entity (without regard as to whether that entity is organized for
profit or not for profit) that is primarily engaged in offering to the general public facilities and services for (i)
the diagnosis or treatment of injury, deformity, or disease; and (ii) surgical, drug treatment, psychiatric, or
obstetric care”
-- §101(27A) of Bankruptcy Code
Includes “health care institution[s]… primarily engaged in offering room, board, laundry, or personal
assistance with activities of daily living and incidentals to activities of daily living” related to SNFs, CCRCs,
long-term care, assisted-living, nursing homes, or retirement centers.
-- §101(27A) of Bankruptcy Code
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Types of Health Care Entities
• Hospitals
• Physician group practices
• Municipalities
• Skilled nursing facilities (SNF)
• Senior Care/Housing/Retirement Centers (e.g. CCRC)
• Hospices
• Home Health
• Acute Care
• Ambulatory Care
• Urgent Care
• VIP/Concierge Doctors
• “Doc in the Box”
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SURGE IN HEALTH CARE FILINGS
Chapter 11 health care bankruptcy filings continue to rise.
• Contributing factors:
▪ Increased competition
▪ Reimbursement rates reductions
▪ Payer pressure
▪ Healthcare mergers and acquisitions
▪ Overexpansion
▪ Rent issues
▪ Increasing regulatory burden (especially difficult for small stand-alone hospitals)
▪ Changes in payer mix
▪ Civil penalties arising from improper billing, fraud, or Stark violations 1
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SURGE IN HEALTH CARE FILINGS
Recent filings:
2018
▪Mayflower Communities Inc. (d/b/a/ The Barrington of Carmel)
▪Senior Care Centers LLC
▪Orion Healthcare Corp.
▪HCR Manorcare
▪Verity Health
▪Magee (Miss.) General Hospital
▪Curae Health
▪Little River Healthcare
▪Florence (Ariz.) Hospital at Anthem
▪Gilbert (Ariz.) Hospital
▪The Miami Medical Center
▪Iron County Medical Center 1
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Bankruptcy Overview
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Types of Bankruptcy Cases
• Most bankruptcy cases in the health care arena are either Chapter 7 cases or Chapter
11 cases
• Chapter 7 – Debtor liquidates its assets
• Trustee is appointed to take title to nonexempt assets of the debtor and monetize them
• In corporate bankruptcies, the corporation or similar entity ceases to exist and the creditors have their
debts paid from net proceeds of the liquidation of assets
• Chapter 11 – Debtor is likely reorganizing (but may also liquidate assets)
• Typically involves operating and then reorganizing or restructuring the business
• If a hospital is organized as a “municipality” it may also be able to file under Chapter
9.
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Chapter 11 Procedural Overview
• Two ways to acquire a health care company in Chapter 11
• Plan of Reorganization –more complex
• “363 Sale” – more streamlined
• Debtor executes a “Stalking Horse” Asset Purchase Agreement, which sets a
baseline for future bidders
• Debtor files motion for approval of marketing and auction process and sale
• Debtor seeks “better” offers than the existing Stalking Horse APA
• Bankruptcy court holds hearing on whether to approve the sale
• Court authorizes the sale and transaction closes.
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The Automatic Stay
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What is the Automatic Stay?
• At the beginning of a bankruptcy, as soon as the petition is filed, an automatic stay
goes into effect
• Generally prohibits creditors and claimants from taking any act to collect or
enforce their claims
• Intended to provide debtors with breathing room to either reorganize or liquidate
• May be subject to severe penalties for violating automatic stay under Section
362(k) of the Bankruptcy Code
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Exceptions to the Automatic Stay
• There are exceptions to the Automatic Stay under Bankruptcy Code Section
362(b)(1)-(28)
• 362(b)(28) – the filing of a petition does not operate as a stay “of the exclusion by
the Secretary of Health and Human Services of the debtor from participation in
the Medicare program or any other Federal health care program…”
• However, the Automatic Stay still applies to termination from participation in
Medicare or Medicaid.
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Alternatives to the Automatic Stay
• Even though exclusion from Federal health care programs is exempted from the
Automatic Stay, there is still protection for debtors.
• Under Section 525(a), the government may not deny, revoke, suspend, or refuse
to renew a license, permit, charter, franchise, or other similar grant to a debtor…
solely because such bankrupt or debtor has been a debtor…
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Protecting the Patients
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Health Care Specific Procedures:
Providing a Reasonable Quality of Care
• Sections 704(a)(12) and 1106(a)(1) require a trustee to use “all reasonable and best efforts” to
transfer patients from a healthcare business that is to be closed to an “appropriate” healthcare
business in the vicinity that provides substantially similar services and a reasonable quality of care.
• Bankruptcy Rule 2015.2 requires the trustee to provide notice of patient transfer to the patient,
the patient’s contact person, and the Patient Care Ombudsman appointed by the Bankruptcy
Court.
• Notice is subject to all non-bankruptcy patient privacy laws
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Health Care Specific Procedures:
Appointing an Ombudsman
• No later than 30 days after commencement of Chapter 7, 9, or 11 of a health care business, 11 U.S.
Code § 333 requires the court to appoint a patient care ombudsman
• § 333(a)(1) of the Bankruptcy Code requires that “[i]f the debtor in a case under Chapter 7, 9 or 11
is a health care business, the court shall order...the appointment of an ombudsman to monitor the
quality of patient care and to represent the interests of the patients of a health care business unless
the court finds that the appointment of such ombudsman is not necessary for the protection of
patients under the specific facts of the case.”
• No ombudsman -- U.S. Trustee or a party in interest must file a motion within 21 days after
commencement of the case, and the Court must find that appointment is not necessary
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Health Care Specific Procedures:
Appointing an Ombudsman
• Patient Care Ombudsman is an advocate for patients.
• Monitors quality of patient care
• Represents interests of patients
• Required to report to bankruptcy court every 60 days under Section 333(b) and Rule 2015.1
• Must be notified by trustee of any patient transfer to another health care business due to closure
• Fees are paid by the estate and should be budgeted for in the DIP or cash collateral motions and
orders
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Health Care Specific Procedures
Protecting Patient Information
•HIPAA creates a duty to maintain patient confidentiality for both health care providers and their
business associates.
•As part of the first-day motions, debtors should file a Motion Authorizing Implementation of
Procedures to Maintain and Protect Confidential Patient Information.
•The treatment of medical records is state-specific, but Section 351 of the Bankruptcy Code and
Bankruptcy Rule 6011 provide for the disposal of records in the event the trustee cannot pay storage
fees under applicable Federal or State law.
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Health Care Specific Procedures
Closing Hospitals
•Comply with WARN Act – requires employers with one hundred or more full-time employees to
notify employees at least sixty days in advance of an intended plant closing or mass layoff
• Certificate of Need – determine if a certificate of need must be obtained from state prior to closing
or transferring.
•Government approval -- Obtain any government approvals necessary for the disposition of assets in
accordance with State law.
•Medical Records – continue to comply with medical records retention requirements
•Pensions– Analyze current status of pension plans and notify Pension Benefit Guaranty Corp.
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Sale of Non-Profit Health Care
Businesses
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Non-Profit Health Care Entities
• 56% of all community hospitals in the United States are non-government, not-
for-profit community hospitals. American Hosp. Ass’n, Fast Facts on US
Hospitals, https://www.aha.org/statistics/fast-facts-us-hospitals (last updated
Jan. 2019).
• In 2005, the Bankruptcy Code was amended to expressly provide that sales of
these non-profits must comply with applicable state law.
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Non-Profit Health Care Entities
• The Board of Directors of non-profit entities owe a duty of obedience to the entity as part of their
fiduciary duties. As part of this duty, directors must carry out the organization’s mission.
• Courts recognize this duty of obedience, especially in Section 363 sales. The “best” offer may be
one that takes into account existing patient concerns and public policy, rather than the best
financial offer received by the debtor.
• Debtors and courts may consider (i) the effects of the sale on the various constituencies and
the communities where the hospital is located, (ii) the short-term and long term interests of
the hospital, and (iii) the resources, intent and conduct of the purchaser.
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Non-Profit Health Care 363 Sales –
Obtaining Regulatory Approvals
• Debtors may require bidders to submit evidence of their ability to obtain necessary
regulatory approvals to consummate sale
• Sales of hospitals are frequently conditioned upon buyer obtaining regulatory approvals
• Due to lengthy approval process for obtaining regulatory approvals, sales of not-for-
profit hospitals often contain provisions for a “sale-leaseback” to accommodate the
buyer
• Buyer manages hospital using Debtor’s license/regulatory consents, pending the
buyer obtaining its own licenses or other regulatory approvals
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Non-Profit Health Care 363 Sales –
Transfer of Non-Profit Assets
• 11 U.S.C. § 363(d): trustee may only sell or lease in accordance with non-
bankruptcy nonprofit law
• 11 U.S.C. § 1129(a)(16): transfers of property must be made in accordance with
applicable non-bankruptcy law for non profits
• 11 U.S.C. § 541(f): tax exempt property under the Internal Revenue Code may be
transferred to an entity that is not such a corporation only under the same
conditions as would apply if the debtor had not filed bankruptcy.
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Other Considerations
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Health Care Specific Considerations:
Treatment of Provider Agreements
• Some disagreement over whether to treat Medicare/Medicaid provider agreements as executory
contracts or as a license.
• Executory contracts need to be assigned under section 365
• Debtor can either assume the contract and cure any existing defaults, or
• Transfer the contract along with any successor liability for prior overpayments from
Medicare or damages from False Claims Act lawsuits.
• Licenses can be sold under Section 363 without the buyer having any successor liability.
• Most bankruptcy courts view provider agreements as executory contracts, but it has been
successfully argued outside of bankruptcy that provider agreements are not contracts.
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Health Care Specific Considerations:
Treatment of Provider Agreements
• Strategies for dealing with executory contract liability relating to provider agreements:
• 1 – Negotiate with the government to set a cap on assumed liabilities
• 2 – Hold back funds from purchase price in escrow to cover potential liabilities
• 3 – Leave provider agreements behind and apply for new ones
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Health Care Specific Considerations:
Setoff or Recoupment of Provider Agreements
•Under Medicare and Medicaid, reimbursements to the provider are often made under provider
agreements before the government agency has determined whether the provider is fully entitled to
reimbursement.
• The provider is legally obligated to return any overpayments
• The return of these overpayments is typically accomplished through the government’s
adjustment/withholding of future payments made to the provider
•In bankruptcy, there is a question of whether these adjustments/withholdings are allowed under
the Automatic Stay. This is governed by whether they are deemed to be setoffs or recoupments
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Health Care Specific Considerations:
Setoff or Recoupment of Provider Agreements
• Setoff – involves “netting out” liability or amounts owed under separate transactions.
• The Automatic Stay applies to setoff adjustments.
• Recoupment – involves “netting out” liability or amounts owed by both the debtor and the creditor
where the amounts owed are from the same transaction.
• The Automatic Stay does not apply to recoupment.
• Courts are divided on the treatment of overpayment adjustments under provider agreements and
what qualifies as being under the same transaction.
• Majority – generally categorize recovery of overpayments as recoupment
• Some courts distinguish between provider “cost report years” as each being a separate
transaction
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Health Care Specific Considerations:
Lender Issues
• Use of accounts receivable as collateral
• Provider AR is frequently used as collateral for loans but is subject to anti-assignment
provisions under 42 U.S.C §§ 1395g(c) and 1396a(32)
• Requires “double lockbox” arrangement where funds are swept daily from borrower’s deposit
account into lender’s account.
• Sweeps need to be based on revocable instructions in compliance with anti-assignment
rules.
• Ombudsman fees are paid for by the estate and need to be budgeted for in the calculation of the
DIP
• Social policy concerns – Lender may not be able to force closure of a hospital so as a practical
matter may be forced to fund a hospital bankruptcy case through providing DIP loan
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ABOUT THE FACULTY
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THAD WILSON – ThadWilson@kslaw.com
Partner, King & Spalding LLP
Thad Wilson is a partner in the Atlanta office of King & Spalding and a member of the firm’s Financial Restructuring
practice. Thad has represented a broad spectrum of clients in financial restructuring, corporate and insolvency
matters, including bankruptcy-related government investigations and appeals. He has represented debtors, secured
and unsecured creditors, and other parties in interest in major Chapter 11 bankruptcy cases.
Thad has substantial experience representing litigants in contested matters, adversary proceedings and other high
stakes litigation in significant Chapter 11 bankruptcy cases and insolvency proceedings involving creditors’ rights,
fraudulent transfers, and alter ego, as well as representing buyers and sellers of distressed assets in Chapter 11
bankruptcy proceedings.
Thad is a member of the American Bankruptcy Institute, the Turnaround Management Association, the Atlanta Bar
Association and the State Bar of Georgia. He is a founding member of the Atlanta chapter of the Turnaround
Management Association NextGen organization and is the group’s immediate past president. In 2014, he was elected
to the initial class of Barristers of the W. Homer Drake, Jr. Georgia Bankruptcy American Inn of Court, of which he is
currently a member.
To read more, go to https://www.financialpoise.com/financialpoisewebinars/faculty/thaddeus-d-wilson/
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MARSHALL GLADE– mglade@glassratner.com
Senior Managing Director, GlassRatner Advisory and Capital Group
Marshall Glade, CPA, is a senior managing director with over 14 years of experience advising clients ranging from small
startups to fortune 500. Since joining GlassRatner, Marshall has worked in corporate finance and restructuring. He has
advised companies through out-of-court restructurings, formal bankruptcy proceedings, formal sales processes, pre-
acquisition due diligence, forensic accounting investigations, complex valuations and liquidation and trustee advisory
work. He has experience in a number of industries, including healthcare, real estate, software, banking and
transportation.
Within the healthcare sector, Marshall’s representative experience includes serving as Chief Restructuring Officer (CRO)
for Campbellton-Graceville Hospital and Regional Health Properties, as well as Financial Advisor to Curae Health,
Pioneer Health, Hutcheson Medical Center, among others. In 2017, Marshall received the Commercial Finance
Association's (CFA) 40 Under 40 Award for his exemplary work in the Bankruptcy/Restructuring realm. Marshall has
published articles in both the Secured Lender and Financier Magazine.
Marshall graduated from the University of Georgia with a Bachelors of Business Administration in Accounting and a
Masters of Accountancy. He is a Certified Public Accountant licensed in the State of Georgia.
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BRIAN BONAVIRI– Brian.Bonaviri@us.gt.com
Senior Manager, Grant Thornton
Brian is a Senior Manager in Grant Thornton’s Strategic Solutions advisory practice located in Charlotte, North
Carolina. Brian has served in the capacity of an advisor to company management as well as secured and unsecured
creditors. His areas of specialization include corporate bankruptcy advisory, financial modeling, strategic planning
and review, and business plan development and assessment.
Brian has more than ten years of advisory experience, and has been with Grant Thornton for over eight years. He has
extensive experience in international business, including advising clients onsite in China, Israel and Saudi Arabia.
Brian has extensive advisory experience across a wide range of industries including healthcare, higher education,
financial services, manufacturing, transportation, food and beverage, software, commercial real estate, and not-for-
profit. Most of his work in the past five years has been focused on the healthcare and higher education sectors.
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ANDREW SHERMAN– asherman@sillscummis.com
Member, Sills Cummis & Gross P.C.
ANDREW H. SHERMAN is Chair of the Sills Cummis & Gross Creditors’ Rights/Bankruptcy Reorganization Practice Group. He has represented
clients in a broad range of complex business reorganizations, debt restructurings and insolvency matters throughout the country. In addition to
advising companies experiencing financial difficulties, Andrew routinely represents lenders and other parties in financings and acquisitions
involving troubled companies. He has focused his practice on representing investment management firms in debt restructuring matters,
commercial workouts and Chapter 11 cases in such cases as Motor Coach Industries Int'l, Inc. and Marcal Paper Mills, Inc. He has also recently
represented the Official Committee of Unsecured Creditors in fourteen (14) recent hospital bankruptcy cases. In addition, he has represented
parties in significant commercial litigation in the New York and New Jersey federal and state courts.
Andrew has been selected for inclusion in the 2012-2019 editions of Chambers USA®* under New Jersey Bankruptcy/Restructuring, the 2007-2019
editions of The Best Lawyers in America®* under Bankruptcy and Creditor-Debtor Rights/Insolvency and Reorganization Law; Litigation –
Bankruptcy, the 2018-2019 editions of IFLR1000 United States: Guide to USA’s Leading Financial & Corporate Law Firms®* under “Highly
Regarded” New Jersey Restructuring and Insolvency, and the 2006-2018 editions of New Jersey Super Lawyers®* under Creditor Debtor Rights:
Business and Bankruptcy: Business. He was also named one of the New Jersey Law Journal’s®* “Jersey Dealmakers of the Year” in 2018.
He is an active member of the American Bankruptcy Institute, currently serving as co-chair of the Commercial and Regulatory Law Committee. He is
also a member of the Turnaround Management Association, the American Bar Association and the New York State Bar Association. Prior to
joining the Firm, Andrew was associated with Parker Chapin Flattau & Klimpl, LLP in New York City. He received his J.D. from Cardozo School
of Law in 1991 and his A.B. from Cornell University in 1988. He is admitted to practice in New Jersey and New York.
* For ranking methodologies, please see www.sillscummis.com/award-methodology.aspx.
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QUESTIONS OR COMMENTS?
If you have any questions about this webinar that you did not get to ask during
the live premiere, or if you are watching this webinar On Demand, please do
not hesitate to email us at info@financialpoise.com with any questions or
comments you may have. Please include the name of the webinar in your email
and we will do our best to provide a timely response.
IMPORTANT NOTE: The material in this presentation is for general educational purposes only. It has been prepared primarily
for attorneys and accountants for use in the pursuit of their continuing legal education and continuing professional education.
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ABOUT DailyDAC
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bankruptcy, receiverships, out-of-court workouts
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Visit us at www.dailydac.com.
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Focus on Health Care (Series: Chapter 11 Special Issues)

  • 1. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Insert the cover image for this webinar on this slide entirely 1
  • 2. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Practical and entertaining education for attorneys, accountants, business owners and executives, and investors. 2
  • 3. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe DISCLAIMER The material in this webinar is for informational purposes only. It should not be considered legal, financial or other professional advice. You should consult with an attorney or other appropriate professional to determine what may be best for your individual needs. While Financial Poise™ takes reasonable steps to ensure the information it publishes is accurate, Financial Poise™ makes no guaranty in this regard. About this PowerPoint: if you are looking at this PowerPoint without the benefit of listening to the conversation that surrounded it then you are doing yourself a disservice. This PowerPoint was prepared in contemplation of being viewed in conjunction with listening to a one hour webinar on the topic 3
  • 4. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Thank You To Our Sponsor 4
  • 5. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe 5
  • 6. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe 6
  • 7. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe MEET THE FACULTY Moderator: Thad Wilson – King & Spalding LLP Panelists: Marshall Glade – GlassRatner Advisory and Capital Group Brian Bonaviri – Grant Thornton LLP Andrew H. Sherman – Sills Cummis & Gross, P.C. 7
  • 8. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe ABOUT THIS WEBINAR: Focus on Health Care Chapter 11 cases involving healthcare providers involves issues that simply do not exist on chapter 11s of other entities. First, public health and safety issues are at issue in a way that generally is not the case with other debtors. There is, consequently, a large state and federal non-bankruptcy law regulatory overlay in such cases to make sure that the care of patients remains paramount. Also helping to effect this is that courts recognize the "duty of obedience" owed by the leadership of a healthcare provider. As a practical matter, the stakeholders with whom a healthcare provider debtor must consider, and deal with, are often much broader than in other Chapter 11 cases. These are some of the issues this webinar addresses. 8
  • 9. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe ABOUT THIS SERIES: Chapter 11 – Special Issues As of this writing (January 2019) many people (economists) with crystal balls (relevant training, experience, and tools) predict that the economy is turning, and not for the better. If correct, one likely result will be a significant uptick in the number of Chapter 11 bankruptcy cases filed by businesses across the American Landscape. Designed for the corporate attorney, litigator, and anyone else who is not a Chapter 11 bankruptcy expert who finds herself stepping into bankruptcy for the first time or only on occasion, each episode in this Financial Poise webinar series takes a deep dive into one aspect of a chapter 11 bankruptcy case at a level that can be understood by the non-expert. 9
  • 10. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe EPISODES IN THIS SERIES 4/17/19 Episode #1: Focus on Retail 5/15/19 Episode #2: Focus on Single Asset Real Estate 6/19/19 Episode #3: Focus on Health Care 1 0 Dates shown are premiere dates. All webinars will be available On Demand approximately 4 weeks after they premiere.
  • 11. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Episode #3: Focus on Health Care 1 1
  • 12. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Health care business – “any public or private entity (without regard as to whether that entity is organized for profit or not for profit) that is primarily engaged in offering to the general public facilities and services for (i) the diagnosis or treatment of injury, deformity, or disease; and (ii) surgical, drug treatment, psychiatric, or obstetric care” -- §101(27A) of Bankruptcy Code Includes “health care institution[s]… primarily engaged in offering room, board, laundry, or personal assistance with activities of daily living and incidentals to activities of daily living” related to SNFs, CCRCs, long-term care, assisted-living, nursing homes, or retirement centers. -- §101(27A) of Bankruptcy Code
  • 13. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Types of Health Care Entities • Hospitals • Physician group practices • Municipalities • Skilled nursing facilities (SNF) • Senior Care/Housing/Retirement Centers (e.g. CCRC) • Hospices • Home Health • Acute Care • Ambulatory Care • Urgent Care • VIP/Concierge Doctors • “Doc in the Box” 1 3
  • 14. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe SURGE IN HEALTH CARE FILINGS Chapter 11 health care bankruptcy filings continue to rise. • Contributing factors: ▪ Increased competition ▪ Reimbursement rates reductions ▪ Payer pressure ▪ Healthcare mergers and acquisitions ▪ Overexpansion ▪ Rent issues ▪ Increasing regulatory burden (especially difficult for small stand-alone hospitals) ▪ Changes in payer mix ▪ Civil penalties arising from improper billing, fraud, or Stark violations 1 4
  • 15. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe SURGE IN HEALTH CARE FILINGS Recent filings: 2018 ▪Mayflower Communities Inc. (d/b/a/ The Barrington of Carmel) ▪Senior Care Centers LLC ▪Orion Healthcare Corp. ▪HCR Manorcare ▪Verity Health ▪Magee (Miss.) General Hospital ▪Curae Health ▪Little River Healthcare ▪Florence (Ariz.) Hospital at Anthem ▪Gilbert (Ariz.) Hospital ▪The Miami Medical Center ▪Iron County Medical Center 1 5
  • 16. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Bankruptcy Overview
  • 17. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Types of Bankruptcy Cases • Most bankruptcy cases in the health care arena are either Chapter 7 cases or Chapter 11 cases • Chapter 7 – Debtor liquidates its assets • Trustee is appointed to take title to nonexempt assets of the debtor and monetize them • In corporate bankruptcies, the corporation or similar entity ceases to exist and the creditors have their debts paid from net proceeds of the liquidation of assets • Chapter 11 – Debtor is likely reorganizing (but may also liquidate assets) • Typically involves operating and then reorganizing or restructuring the business • If a hospital is organized as a “municipality” it may also be able to file under Chapter 9. 1 7
  • 18. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Chapter 11 Procedural Overview • Two ways to acquire a health care company in Chapter 11 • Plan of Reorganization –more complex • “363 Sale” – more streamlined • Debtor executes a “Stalking Horse” Asset Purchase Agreement, which sets a baseline for future bidders • Debtor files motion for approval of marketing and auction process and sale • Debtor seeks “better” offers than the existing Stalking Horse APA • Bankruptcy court holds hearing on whether to approve the sale • Court authorizes the sale and transaction closes. 1 8
  • 19. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe The Automatic Stay
  • 20. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe What is the Automatic Stay? • At the beginning of a bankruptcy, as soon as the petition is filed, an automatic stay goes into effect • Generally prohibits creditors and claimants from taking any act to collect or enforce their claims • Intended to provide debtors with breathing room to either reorganize or liquidate • May be subject to severe penalties for violating automatic stay under Section 362(k) of the Bankruptcy Code 2 0
  • 21. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Exceptions to the Automatic Stay • There are exceptions to the Automatic Stay under Bankruptcy Code Section 362(b)(1)-(28) • 362(b)(28) – the filing of a petition does not operate as a stay “of the exclusion by the Secretary of Health and Human Services of the debtor from participation in the Medicare program or any other Federal health care program…” • However, the Automatic Stay still applies to termination from participation in Medicare or Medicaid. 2 1
  • 22. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Alternatives to the Automatic Stay • Even though exclusion from Federal health care programs is exempted from the Automatic Stay, there is still protection for debtors. • Under Section 525(a), the government may not deny, revoke, suspend, or refuse to renew a license, permit, charter, franchise, or other similar grant to a debtor… solely because such bankrupt or debtor has been a debtor… 2 2
  • 23. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Protecting the Patients
  • 24. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Health Care Specific Procedures: Providing a Reasonable Quality of Care • Sections 704(a)(12) and 1106(a)(1) require a trustee to use “all reasonable and best efforts” to transfer patients from a healthcare business that is to be closed to an “appropriate” healthcare business in the vicinity that provides substantially similar services and a reasonable quality of care. • Bankruptcy Rule 2015.2 requires the trustee to provide notice of patient transfer to the patient, the patient’s contact person, and the Patient Care Ombudsman appointed by the Bankruptcy Court. • Notice is subject to all non-bankruptcy patient privacy laws 2 4
  • 25. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Health Care Specific Procedures: Appointing an Ombudsman • No later than 30 days after commencement of Chapter 7, 9, or 11 of a health care business, 11 U.S. Code § 333 requires the court to appoint a patient care ombudsman • § 333(a)(1) of the Bankruptcy Code requires that “[i]f the debtor in a case under Chapter 7, 9 or 11 is a health care business, the court shall order...the appointment of an ombudsman to monitor the quality of patient care and to represent the interests of the patients of a health care business unless the court finds that the appointment of such ombudsman is not necessary for the protection of patients under the specific facts of the case.” • No ombudsman -- U.S. Trustee or a party in interest must file a motion within 21 days after commencement of the case, and the Court must find that appointment is not necessary 2 5
  • 26. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Health Care Specific Procedures: Appointing an Ombudsman • Patient Care Ombudsman is an advocate for patients. • Monitors quality of patient care • Represents interests of patients • Required to report to bankruptcy court every 60 days under Section 333(b) and Rule 2015.1 • Must be notified by trustee of any patient transfer to another health care business due to closure • Fees are paid by the estate and should be budgeted for in the DIP or cash collateral motions and orders 2 6
  • 27. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Health Care Specific Procedures Protecting Patient Information •HIPAA creates a duty to maintain patient confidentiality for both health care providers and their business associates. •As part of the first-day motions, debtors should file a Motion Authorizing Implementation of Procedures to Maintain and Protect Confidential Patient Information. •The treatment of medical records is state-specific, but Section 351 of the Bankruptcy Code and Bankruptcy Rule 6011 provide for the disposal of records in the event the trustee cannot pay storage fees under applicable Federal or State law. 2 7
  • 28. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Health Care Specific Procedures Closing Hospitals •Comply with WARN Act – requires employers with one hundred or more full-time employees to notify employees at least sixty days in advance of an intended plant closing or mass layoff • Certificate of Need – determine if a certificate of need must be obtained from state prior to closing or transferring. •Government approval -- Obtain any government approvals necessary for the disposition of assets in accordance with State law. •Medical Records – continue to comply with medical records retention requirements •Pensions– Analyze current status of pension plans and notify Pension Benefit Guaranty Corp. 2 8
  • 29. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Sale of Non-Profit Health Care Businesses
  • 30. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Non-Profit Health Care Entities • 56% of all community hospitals in the United States are non-government, not- for-profit community hospitals. American Hosp. Ass’n, Fast Facts on US Hospitals, https://www.aha.org/statistics/fast-facts-us-hospitals (last updated Jan. 2019). • In 2005, the Bankruptcy Code was amended to expressly provide that sales of these non-profits must comply with applicable state law. 3 0
  • 31. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Non-Profit Health Care Entities • The Board of Directors of non-profit entities owe a duty of obedience to the entity as part of their fiduciary duties. As part of this duty, directors must carry out the organization’s mission. • Courts recognize this duty of obedience, especially in Section 363 sales. The “best” offer may be one that takes into account existing patient concerns and public policy, rather than the best financial offer received by the debtor. • Debtors and courts may consider (i) the effects of the sale on the various constituencies and the communities where the hospital is located, (ii) the short-term and long term interests of the hospital, and (iii) the resources, intent and conduct of the purchaser. 3 1
  • 32. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Non-Profit Health Care 363 Sales – Obtaining Regulatory Approvals • Debtors may require bidders to submit evidence of their ability to obtain necessary regulatory approvals to consummate sale • Sales of hospitals are frequently conditioned upon buyer obtaining regulatory approvals • Due to lengthy approval process for obtaining regulatory approvals, sales of not-for- profit hospitals often contain provisions for a “sale-leaseback” to accommodate the buyer • Buyer manages hospital using Debtor’s license/regulatory consents, pending the buyer obtaining its own licenses or other regulatory approvals 3 2
  • 33. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Non-Profit Health Care 363 Sales – Transfer of Non-Profit Assets • 11 U.S.C. § 363(d): trustee may only sell or lease in accordance with non- bankruptcy nonprofit law • 11 U.S.C. § 1129(a)(16): transfers of property must be made in accordance with applicable non-bankruptcy law for non profits • 11 U.S.C. § 541(f): tax exempt property under the Internal Revenue Code may be transferred to an entity that is not such a corporation only under the same conditions as would apply if the debtor had not filed bankruptcy. 3 3
  • 34. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Other Considerations
  • 35. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Health Care Specific Considerations: Treatment of Provider Agreements • Some disagreement over whether to treat Medicare/Medicaid provider agreements as executory contracts or as a license. • Executory contracts need to be assigned under section 365 • Debtor can either assume the contract and cure any existing defaults, or • Transfer the contract along with any successor liability for prior overpayments from Medicare or damages from False Claims Act lawsuits. • Licenses can be sold under Section 363 without the buyer having any successor liability. • Most bankruptcy courts view provider agreements as executory contracts, but it has been successfully argued outside of bankruptcy that provider agreements are not contracts. 3 5
  • 36. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Health Care Specific Considerations: Treatment of Provider Agreements • Strategies for dealing with executory contract liability relating to provider agreements: • 1 – Negotiate with the government to set a cap on assumed liabilities • 2 – Hold back funds from purchase price in escrow to cover potential liabilities • 3 – Leave provider agreements behind and apply for new ones 3 6
  • 37. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Health Care Specific Considerations: Setoff or Recoupment of Provider Agreements •Under Medicare and Medicaid, reimbursements to the provider are often made under provider agreements before the government agency has determined whether the provider is fully entitled to reimbursement. • The provider is legally obligated to return any overpayments • The return of these overpayments is typically accomplished through the government’s adjustment/withholding of future payments made to the provider •In bankruptcy, there is a question of whether these adjustments/withholdings are allowed under the Automatic Stay. This is governed by whether they are deemed to be setoffs or recoupments 3 7
  • 38. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Health Care Specific Considerations: Setoff or Recoupment of Provider Agreements • Setoff – involves “netting out” liability or amounts owed under separate transactions. • The Automatic Stay applies to setoff adjustments. • Recoupment – involves “netting out” liability or amounts owed by both the debtor and the creditor where the amounts owed are from the same transaction. • The Automatic Stay does not apply to recoupment. • Courts are divided on the treatment of overpayment adjustments under provider agreements and what qualifies as being under the same transaction. • Majority – generally categorize recovery of overpayments as recoupment • Some courts distinguish between provider “cost report years” as each being a separate transaction 3 8
  • 39. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe Health Care Specific Considerations: Lender Issues • Use of accounts receivable as collateral • Provider AR is frequently used as collateral for loans but is subject to anti-assignment provisions under 42 U.S.C §§ 1395g(c) and 1396a(32) • Requires “double lockbox” arrangement where funds are swept daily from borrower’s deposit account into lender’s account. • Sweeps need to be based on revocable instructions in compliance with anti-assignment rules. • Ombudsman fees are paid for by the estate and need to be budgeted for in the calculation of the DIP • Social policy concerns – Lender may not be able to force closure of a hospital so as a practical matter may be forced to fund a hospital bankruptcy case through providing DIP loan 3 9
  • 40. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe ABOUT THE FACULTY 4 0
  • 41. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe THAD WILSON – ThadWilson@kslaw.com Partner, King & Spalding LLP Thad Wilson is a partner in the Atlanta office of King & Spalding and a member of the firm’s Financial Restructuring practice. Thad has represented a broad spectrum of clients in financial restructuring, corporate and insolvency matters, including bankruptcy-related government investigations and appeals. He has represented debtors, secured and unsecured creditors, and other parties in interest in major Chapter 11 bankruptcy cases. Thad has substantial experience representing litigants in contested matters, adversary proceedings and other high stakes litigation in significant Chapter 11 bankruptcy cases and insolvency proceedings involving creditors’ rights, fraudulent transfers, and alter ego, as well as representing buyers and sellers of distressed assets in Chapter 11 bankruptcy proceedings. Thad is a member of the American Bankruptcy Institute, the Turnaround Management Association, the Atlanta Bar Association and the State Bar of Georgia. He is a founding member of the Atlanta chapter of the Turnaround Management Association NextGen organization and is the group’s immediate past president. In 2014, he was elected to the initial class of Barristers of the W. Homer Drake, Jr. Georgia Bankruptcy American Inn of Court, of which he is currently a member. To read more, go to https://www.financialpoise.com/financialpoisewebinars/faculty/thaddeus-d-wilson/ 4 1
  • 42. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe MARSHALL GLADE– mglade@glassratner.com Senior Managing Director, GlassRatner Advisory and Capital Group Marshall Glade, CPA, is a senior managing director with over 14 years of experience advising clients ranging from small startups to fortune 500. Since joining GlassRatner, Marshall has worked in corporate finance and restructuring. He has advised companies through out-of-court restructurings, formal bankruptcy proceedings, formal sales processes, pre- acquisition due diligence, forensic accounting investigations, complex valuations and liquidation and trustee advisory work. He has experience in a number of industries, including healthcare, real estate, software, banking and transportation. Within the healthcare sector, Marshall’s representative experience includes serving as Chief Restructuring Officer (CRO) for Campbellton-Graceville Hospital and Regional Health Properties, as well as Financial Advisor to Curae Health, Pioneer Health, Hutcheson Medical Center, among others. In 2017, Marshall received the Commercial Finance Association's (CFA) 40 Under 40 Award for his exemplary work in the Bankruptcy/Restructuring realm. Marshall has published articles in both the Secured Lender and Financier Magazine. Marshall graduated from the University of Georgia with a Bachelors of Business Administration in Accounting and a Masters of Accountancy. He is a Certified Public Accountant licensed in the State of Georgia. 4 2
  • 43. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe BRIAN BONAVIRI– Brian.Bonaviri@us.gt.com Senior Manager, Grant Thornton Brian is a Senior Manager in Grant Thornton’s Strategic Solutions advisory practice located in Charlotte, North Carolina. Brian has served in the capacity of an advisor to company management as well as secured and unsecured creditors. His areas of specialization include corporate bankruptcy advisory, financial modeling, strategic planning and review, and business plan development and assessment. Brian has more than ten years of advisory experience, and has been with Grant Thornton for over eight years. He has extensive experience in international business, including advising clients onsite in China, Israel and Saudi Arabia. Brian has extensive advisory experience across a wide range of industries including healthcare, higher education, financial services, manufacturing, transportation, food and beverage, software, commercial real estate, and not-for- profit. Most of his work in the past five years has been focused on the healthcare and higher education sectors. 4 3
  • 44. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe ANDREW SHERMAN– asherman@sillscummis.com Member, Sills Cummis & Gross P.C. ANDREW H. SHERMAN is Chair of the Sills Cummis & Gross Creditors’ Rights/Bankruptcy Reorganization Practice Group. He has represented clients in a broad range of complex business reorganizations, debt restructurings and insolvency matters throughout the country. In addition to advising companies experiencing financial difficulties, Andrew routinely represents lenders and other parties in financings and acquisitions involving troubled companies. He has focused his practice on representing investment management firms in debt restructuring matters, commercial workouts and Chapter 11 cases in such cases as Motor Coach Industries Int'l, Inc. and Marcal Paper Mills, Inc. He has also recently represented the Official Committee of Unsecured Creditors in fourteen (14) recent hospital bankruptcy cases. In addition, he has represented parties in significant commercial litigation in the New York and New Jersey federal and state courts. Andrew has been selected for inclusion in the 2012-2019 editions of Chambers USA®* under New Jersey Bankruptcy/Restructuring, the 2007-2019 editions of The Best Lawyers in America®* under Bankruptcy and Creditor-Debtor Rights/Insolvency and Reorganization Law; Litigation – Bankruptcy, the 2018-2019 editions of IFLR1000 United States: Guide to USA’s Leading Financial & Corporate Law Firms®* under “Highly Regarded” New Jersey Restructuring and Insolvency, and the 2006-2018 editions of New Jersey Super Lawyers®* under Creditor Debtor Rights: Business and Bankruptcy: Business. He was also named one of the New Jersey Law Journal’s®* “Jersey Dealmakers of the Year” in 2018. He is an active member of the American Bankruptcy Institute, currently serving as co-chair of the Commercial and Regulatory Law Committee. He is also a member of the Turnaround Management Association, the American Bar Association and the New York State Bar Association. Prior to joining the Firm, Andrew was associated with Parker Chapin Flattau & Klimpl, LLP in New York City. He received his J.D. from Cardozo School of Law in 1991 and his A.B. from Cornell University in 1988. He is admitted to practice in New Jersey and New York. * For ranking methodologies, please see www.sillscummis.com/award-methodology.aspx. 4 4
  • 45. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe QUESTIONS OR COMMENTS? If you have any questions about this webinar that you did not get to ask during the live premiere, or if you are watching this webinar On Demand, please do not hesitate to email us at info@financialpoise.com with any questions or comments you may have. Please include the name of the webinar in your email and we will do our best to provide a timely response. IMPORTANT NOTE: The material in this presentation is for general educational purposes only. It has been prepared primarily for attorneys and accountants for use in the pursuit of their continuing legal education and continuing professional education. 4 5
  • 46. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe ABOUT DailyDAC DailyDAC.com is the leading source of information about assignments, article 9, bankruptcy, receiverships, out-of-court workouts and vulture investing, designed for business owners and vulture investors. Visit us at www.dailydac.com. 4 6 Premium Public Notice Service DailyDAC’s Premium Public Notice Service helps market asset sales on behalf of fiduciaries (e.g., Chapter 11 debtors-in- possession and committees, trustees, receivers, assignees), secured lenders selling collateral under UCC Article 9, and auctioneers to a very large and self-selected group of potential bidders and their advisors. The Service also assists with noticing other events, deadlines, and milestones – including tombstones and other press releases. Our free weekly newsletter, DailyDAC contains our latest bankruptcy article, current Public Notices and all opportunistic deals added to our proprietary database that week. Sign up at: https://www.dailydac.com/dacyak-weekly-newsletter-signup/
  • 47. Copyright © 2019 by DailyDAC, LLC d/b/a Financial Poise Webinars™ Receive our free weekly newsletter at www.financialpoise.com/subscribe ABOUT FINANCIAL POISE DailyDAC LLC, d/b/a Financial Poise™ provides continuing education to attorneys, accountants, business owners and executives, and investors. Its websites, webinars, and books provide Plain English, entertaining, explanations about legal, financial, and other subjects of interest to these audiences. Visit us at www.financialpoise.com. 4 7 Our free weekly newsletter, Financial Poise Weekly, educates readers about business, business law, finance, and investing. To receive it simply add yourself by going to: https://www.financialpoise.com/newsletter/ Email addresses are never sold to or shared with third parties.