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The DOJ Enters Another FCA Lawsuit Against UnitedHealth

The U.S. Department of Justice (DOJ) recently filed its complaint in intervention in another whistleblower lawsuit brought under the False Claims Act against the nation’s largest owner and operator of Medicare Advantage (MA)...more

Courts’ Consistent Application of Stevens to State Institutions of Higher Learning

The United States Supreme Court recently declined review of the First Circuit Court of Appeals’ ruling that the University of Massachusetts Medical School was an “arm of the state,” and thus, not subject to the federal False...more

A Tale of Two Escobars: Federal Courts Begin Grappling with Opposing Views of “Materiality”

On June 16, 2016, the U.S. Supreme Court issued a highly anticipated opinion in Universal Health Services, Inc. v. U.S. ex rel. Escobar, which for the first time expressly recognized implied certification as a viable theory...more

No Longer Implied: Supreme Court Expressly Recognizes Implied Certification as a Theory of Liability Under the False Claims Act

Yesterday, the U.S. Supreme Court issued a long-anticipated decision on the viability of the “implied certification” theory of liability under the False Claims Act (FCA). In Universal Health Services, Inc. v. United States ex...more

Differences in Medical Opinions: Not Enough to Prove FCA Liability

In a $200 million False Claims Act (FCA) litigation with certain twists and turns, the U.S. District Court for the Northern District of Alabama recently found that the federal government failed to show that claims submitted...more

Caution: False Claims Act Penalties Poised to Double

A preview of the effects that a provision in the Bipartisan Budget Act of 2015 will have on healthcare providers came to light this week when the Railroad Retirement Board (Board) published an interim final rule implementing...more

The Deeper Dive: The Final Overpayment Rule

The Centers for Medicare and Medicaid Services (CMS) recently issued its final rule for Reporting and Returning of Overpayments (Final Rule). The Final Rule implements section 1128J(d) of the Social Security Act, which...more

Breaking News: 60-Day Overpayment Rule Finalized

The Centers for Medicare and Medicaid Services (CMS) released its final rule implementing Section 6402(a) of the Affordable Care Act that requires Medicare providers and suppliers to report and return overpayments within 60...more

Implied Certification and the FCA: Legally False or a False Legality? The Supreme Court Is Set to Decide

The United States Supreme Court recently granted certiorari in the case of Universal Health Services, Inc. v. U.S. ex rel. Escobar, No. 15-7, which places implied certification under the False Claims Act (FCA) squarely in the...more

DOJ Takes Aim at Responsible Individuals in Corporate Investigations

U.S. Deputy Attorney General Sally Quillian Yates recently announced new instructions for attorneys at the U.S. Department of Justice (DOJ), outlining in a memorandum the DOJ’s policies with respect to civil and criminal...more

Texas Surgical Centers: Aetna Improperly Denies or Underpays Out-of-Network Claims

Aetna is now facing another set of claims calling into question its determination and payment methodology for out-of-network reimbursement. On September 4, 2015, six surgical centers in Texas (Allied Center for Special...more

Texas Hospital Strikes Back at Aetna

On February 23, 2015, Aetna filed suit in Texas federal court against Robert A. Behar, M.D. and North Cypress Medical Center (North Cypress), alleging that Dr. Behar, the CEO of North Cypress, offered impermissible ownership...more

Kane and the “60-Day Rule”: The Unforgiving World of Medicare and Medicaid Overpayments

The Southern District of New York has spoken on one of the first issues to confront those seeking compliance with the new “60-day rule” under the Affordable Care Act (ACA), and it does not bode well for defendant hospitals...more

HHS OIG Creates New Taskforce to Pursue Civil Monetary Penalties and Exclusions

At the annual meeting of the American Health Lawyers Association (AHLA) held this week in Washington D.C., the U.S. Department of Health and Human Services Office of Inspector General (OIG) announced a new legal team...more

Supreme Court Decision Has Good News and Bad News for Those Facing False Claims Act Litigation

On May 26, 2015, the Supreme Court of the United States (SCOTUS) issued an opinion in a federal False Claims Act (FCA) case that resolves two important procedural points litigants face: the tolling of the six-year statute of...more

OIG Provides Additional Compliance Guidance for Healthcare Governing Boards

On April 20, 2015, the HHS Office of Inspector General (HHS OIG), in collaboration with the American Health Lawyers Association (AHLA), the Association of Healthcare Internal Auditors (AHIA), and the Health Care Compliance...more

Aetna Out of Patience With Hospital’s Alleged Out-of-Network Billing Scheme

Aetna Life Insurance Company (Aetna) is going on the offensive against a Northwest Houston hospital with an out-of-network strategy. On February 23, 2015, Aetna filed suit in Texas federal court against Robert A. Behar, M.D....more

Breaking News: CMS Delays Final Overpayment Rule

Today, the Centers for Medicare and Medicaid Services (CMS) announced that it is extending the deadline to finalize the rule implementing the Affordable Care Act provision that requires providers to timely report and return...more

New Limitations on RAC Program

In March 2014, CMS temporarily suspended the Recovery Audit Contractor (RAC) program until it secured new contracts. The contracts for the program expired in June 2014, and in August, CMS said that it would restart the...more

CMS Offer Deadline to Settle Hospital Inpatient Claim Appeals Draws Near

In an attempt to clear the backlog of appeals of short inpatient stays, CMS recently announced a settlement offer for hospitals with claims currently pending in the appeals process. In exchange for withdrawal of their...more

10/6/2014  /  CMS , Healthcare , Hospitals , Inpatient Billing

Summer Fraud and Abuse Roundup

The federal government was busy over the summer when it came to decisions and settlements under the Stark Law, anti-kickback law and federal False Claims Act. This article revisits recent developments with respect to...more

OIG Revamps Regulations Concerning CMPs and Exclusion

In a pair of proposed rules published in May, the HHS OIG unveiled changes to the regulations concerning OIG’s authority to impose civil monetary penalties (CMPs) and exclude individuals and entities from participation in...more

CMS Announces Changes to RAC Program; Temporary Pause in Document Requests

The Centers for Medicare & Medicaid Services (CMS) recently published an announcement indicating that the agency is “in the procurement process for the next round of Recovery Audit Program Contracts” and is winding down its...more

HHS's Mixed Messages: Identifying a Federal Healthcare Program When You See It

Recent seemingly contrary determinations by the U.S. Department of Health and Human Services (HHS) have fueled industry speculation regarding whether qualified health plans (QHPs) available on the health insurance exchanges...more

Paying for Family Vacations With NIH Funds Triggers FCA Lawsuit and Settlement

Northwestern University will pay $2.93 million to settle a federal False Claims Act (FCA) lawsuit brought by a former employee who alleged Northwestern allowed a researcher to submit false claims under certain cancer research...more

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