On December 7, 2016, the HHS Office of Inspector General (OIG) finalized a set of rules first proposed in 2014 adding new anti-kickback law safe harbors and protecting additional conduct from enforcement under the civil...more
Now that the kids are back in school and summer vacations are in the rearview mirror, it’s time to catch up on recent fraud and abuse developments. The federal government was busy this summer negotiating a pair of settlements...more
The U.S. Supreme Court recently held oral arguments in the case of Universal Health Services, Inc. v. U.S. ex rel. Escobar, No. 15-7, which is set to decide the viability of implied certification under the FCA. As discussed...more
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 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
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
In its calendar year 2016 Physician Fee Schedule Final Rule published in the Federal Register on November 16, 2015 (Final Rule), the Centers for Medicare and Medicaid Services (CMS) finalized amendments to the federal...more
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
10/12/2015
/ Best Practices ,
Corporate Investigations ,
Department of Justice (DOJ) ,
Enforcement Actions ,
False Claims Act (FCA) ,
Federal Prosecutors ,
Health Care Providers ,
Healthcare ,
Misappropriation ,
Professional Misconduct ,
Yates Memorandum
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
8/31/2015
/ Aetna ,
Breach of Duty ,
Contingency Fees ,
Employee Retirement Income Security Act (ERISA) ,
Fiduciary Duty ,
Healthcare ,
Healthcare Fraud ,
Hospitals ,
Insurance Industry ,
Lanham Act ,
Life Insurance ,
Malicious Prosecution ,
Out of Network Provider ,
Patient Referrals ,
Real Party in Interest ,
RICO ,
Tortious Interference
On July 15, 2015, the Centers for Medicare and Medicaid Services (CMS) published the calendar year (CY) 2016 Physician Fee Schedule Proposed Rule. In addition to updating several traditional Part B payment policies, the...more
7/28/2015
/ Affordable Care Act ,
Centers for Medicare & Medicaid Services (CMS) ,
CLIA ,
Compliance ,
FQHC ,
Healthcare ,
Hospitals ,
Medicaid ,
Medicare ,
Medicare Part B ,
Physician Fee Schedule ,
Physicians ,
Rural Health Care Providers ,
Self-Referral ,
Stark Law ,
Tuomey
The U.S. Court of Appeals for the Fourth Circuit recently upheld the judgment against Tuomey Healthcare System, Inc. (Tuomey), in a qui tam False Claims Act case predicated on Stark Law violations. The district court in the...more
On June 1, 2015, Texas Governor Greg Abbott signed House Bill 574 into law protecting physicians and other providers from having their participating provider agreements terminated by an insurer solely because the provider’s...more
The HHS OIG recently issued a brief fraud alert (Fraud Alert) reminding physicians that inappropriate compensation arrangements may lead to enforcement actions under the federal anti-kickback statute and Civil Monetary...more
6/25/2015
/ Anti-Kickback Statute ,
CMP Law ,
Department of Health and Human Services (HHS) ,
Healthcare ,
Hospitals ,
Medical Directors ,
OIG ,
Patient Referrals ,
Physician Compensation Arrangements ,
Risk Alert ,
Stark Law
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
6/1/2015
/ False Claims Act (FCA) ,
First-to-File ,
Health Care Providers ,
Healthcare ,
KBR (formerly Kellogg Brown & Root) ,
Popular ,
Qui Tam ,
SCOTUS ,
Statute of Limitations ,
Whistleblowers ,
WSLA
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
The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently issued an advisory opinion approving an arrangement whereby a licensed entity providing services under a state program for...more
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
On October 3, 2014, the U.S. Department of Health and Human Services Office of Inspector General (OIG) published an unexpected, yet long-awaited, set of proposed rules that would add new anti-kickback law safe harbors,...more
10/17/2014
/ Affordable Care Act ,
Ambulance Providers ,
Anti-Kickback Statute ,
CMP Law ,
Gainsharing ,
Healthcare ,
Medicaid ,
Medicare ,
Medicare Part D ,
OIG ,
Pharmacies ,
Proposed Regulation ,
Safe Harbors
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
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
All Children’s Health System (ACHS) will pay the federal government and state of Florida $7 million to settle allegations that it violated the federal and Florida False Claims Act statutes by submitting claims to Medicaid...more
According to minutes filed in the U.S. District Court for the Middle District of Florida, Halifax Hospital Medical Center (Halifax) and the U.S. Department of Justice (DOJ) have reached a settlement in the pending False...more
As the final days of 2013 passed and the sunset of the Stark Law exception and anti-kickback law safe harbor for electronic health record (EHR) donations loomed nearer, the U.S. Department of Health and Human Services (HHS)...more
On January 8, 2014, the U.S. district judge in the Halifax Hospital Medical Center (Hospital) case pending in the Middle District of Florida granted the Hospital's motion to dismiss all of the relator's anti-kickback law...more
On the heels of the landmark Tuomey case (see the October 3, 2013 issue of the Health Law Update), the federal government recently has seen success in two more False Claims Act cases predicated on alleged Stark Law...more