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False Claims Act “Implied Certification” Update: Supreme Court Oral Argument Forecasts Continued Vitality of Controversial...

The U.S. Supreme Court heard oral argument on April 19, 2016, in United Health Services v. United States ex rel. Escobar, No. 15-7, a case expected to resolve the current split among federal appellate courts on the so-called...more

Supreme Court Hears Oral Arguments in Significant False Claims Act Case

Our colleagues Jackie Baratian and Jason Popp summarize...the oral argument for Universal Health Services v. United Sates ex rel. Escobar heard by the U.S. Supreme Court on Tuesday, April 19th, laying out the various...more

Insurer Actions Cut the Heart Out of Out-of-Network Providers

Aetna Life Insurance Company recently won a $37 million verdict against a group of Northern California surgical centers, Bay Area Surgical Management, LLC and its affiliates (collectively, Bay Area), for an alleged...more

Did the FCA’s “Implied Certification” Theory Dodge a Bullet?

Yesterday’s argument before the Supreme Court in Universal Health Services, Inc. v. U.S. ex rel. Escobar had the potential to put false claims based on an “implied certification” in the crosshairs. Instead, based on the...more

Compliance With Medicare Secondary Payer Act At Issue In Auto Insurance Case

A recent decision in the District of New Jersey addressed an auto insurer’s obligations to comply with the Medicare Secondary Payer Act. Auto insurers may wish to review their practices and procedures in light of this...more

Public disclosure bar prohibits "bounty-hunting" relators from filing duplicative FCA claims

The United States Court of Appeals for the Seventh Circuit has issued an opinion that underscores the importance of the "public disclosure bar" in False Claims Act (FCA) litigation. The court affirmed a lower court’s...more

More Whistleblowing Means More Worries for Employers

If you are an employer in the health care or defense industry, in addition to compliance with the panoply of employment laws you must adhere to, employers must also be attuned to their exposure to whistleblower claims under...more

Final Curtain Call for Tuomey: Long-Running FCA/Stark Case Settled

After 10 years of litigation, including two trials and appeals to the 4th Circuit Court of Appeals, the U.S. Department of Justice (DOJ) and Tuomey Healthcare System (Tuomey) have entered into a settlement of DOJ's action...more

Record-breaking FCA settlements underscore importance of Stark Law compliance

In September and October, the Department of Justice (DOJ) announced four record-breaking False Claims Act settlements – ranging from $25 million to $115 million – involving health care systems that allegedly made improper...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

Suing the Hand that Feeds You

Jeffrey Jacobs alleges that Idaho’s Pocatello Hospital violated the False Claims Act because of physician recruitment contracts that were overly generous to his practice group. Jeff should know because he was recruited under...more

Uncovering the mysteries behind GME payments for Medicare Advantage patients: Carve-outs and shadow bills

Medicare makes graduate medical education (GME) payments to teaching hospitals to pay Medicare's share of the teaching and patient care costs associated with Medicare Advantage (MA) patients. Under the Balanced Budget Act...more

OMB Reviewing New Final Rule on ACO Waivers

Joint waivers issued by the Centers for Medicare and Medicaid Services (CMS) and HHS Office of Inspector General (OIG) relating the application of the physician self-referral law, the Federal anti-kickback statute, and...more

West Coast States Bolster Momentum for Pharmacist Provider Status Reforms

In recent years, legislative reforms have been introduced that recognize pharmacists as reimbursement-eligible providers under government-funded health care programs. While these efforts have attracted significant media and...more

When a Violation of a Rule or Regulation Becomes an FCA Violation: Understanding the Distinction Between Conditions of Payment and...

If you read one thing… - The False Claims Act’s (FCA) language, structure, court precedent and purpose limit its application to only regulatory breaches that are conditions of payment and not conditions of...more

CMS Releases Proposed Rule Reforming Medicare CLFS Payment Rates

The Centers for Medicare & Medicaid Services (“CMS”) released a proposed rule [CMS-1621-P] in accordance with Section 216 of the Protecting Access to Medicare Act of 2014 (“PAMA”), which establishes a new payment methodology...more

Huge Stark Law Hospital Settlements and Physician Culpability - The New Normal Post-Tuomey?

After the federal government’s victory against Tuomey Hospital, we have seen an increasing number of large False Claims Act (FCA) settlements with hospitals involving Stark Law allegations. Relators are even citing, as...more

Medicare GME payments and hospital mergers: A hotbed of issues

Many hospital sale and affiliation transactions involve teaching hospitals. Whether the teaching hospital involved is new to training residents or is part of a long-established teaching program, the parties will need to work...more

Broward Health Wins Most-Illegal-Physician-Comp

Okay, there’s not really a Most-Illegal-Physician-Compensation Prize. But if there were, Florida’s North Broward Hospital District would have won in a walk. That’s why the district has agreed to pay the government $69.5...more

Prosecuting Doctors for Medicare Fraud

Federal prosecutors have turned their attention to physicians for Medicare fraud prosecution. Physicians who participate in the Medicare program have to be aware of the significant risks of Medicare fraud....more

Proposed Changes to Stark Rule Would Create New Hospital Exceptions and Lessen Burden of Self-Disclosures

In a development that is limited in scope but still welcomed by hospitals, the proposed 2016 Physician Fee Schedule proposes a number of new exceptions to the physician self-referral or Stark law and other refinements that...more

CMS Releases Data Regarding Hospital and Physician Utilization

CMS recently announced that it would be releasing Medicare hospital utilization and payment data, as well as physician and supplier utilization and payment data. This is the third year that the hospital data has been released...more

DOJ Hires Compliance Counsel to Aid in Charging Decisions

In today’s robust enforcement climate, most companies have taken at least the first steps towards establishing a formal corporate compliance program. The mere existence of such a program, however, will not by itself protect a...more

The Clock’s Running Fast: SDNY Is First to Interpret “Identification” Under the FCA’s “60-Day Rule” for Government Overpayments

On August 3, 2015, in United States ex rel. Kane v. Healthfirst, Inc., et al., No. 1:11-cv-02325 (S.D.N.Y. Aug. 3, 2015), the United States District Court for the Southern District of New York issued the first reported...more

Defrauding Medicare — A Little Help from the Private Sector?

The headline on Medicare last week was astounding — $60 billion (not million) was lost each year to Medicare fraud, large numbers of fraudulent providers were providing fake or bad addresses – meaning locations including...more

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