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7th Circuit Requires Objective Standards When Pleading Medical Necessity Under the FCA

The Seventh Circuit recently added an arrow to a False Claims Act (FCA) defendant's quiver by requiring relators to plead fraud allegations based on objective criteria pursuant to Fed. R. Civ. P. 9(b). This ruling will...more

Recent Significant Case Law Developments Regarding What Constitutes a Reckless Interpretation of a Law and When Retention of an...

Key Points: - Learn the latest case law developments regarding what evidence the government or the relator must establish to prove that the defendant “recklessly” interpreted a statute or regulation in violation of the...more

Insights Conversations: How Government Health Care Investigations May Be Shifting

The Department of Justice (DOJ) has long had the advantage when investigating False Claims Act (FCA) cases against health care companies. However, recent changes in the courts, including a unanimous U.S. Supreme Court...more

October 17th Compliance Deadline for HHS Nondiscrimination Notifications Approaches

On May 18, 2016, the United States Department of Health and Human Services (“HHS”) Office for Civil Rights (“OCR”) published a final rule implementing Section 1557 of the Affordable Care Act. Among other topics, the final...more

Notable False Claims Act decision in California attempts to restrict Escobar

Last Tuesday, September 20, 2016, the US District Court for the Northern District of California held that the Supreme Court’s decision in Universal Health Services, Inc. v. United States ex rel. Escobar, 136 S. Ct. 1989...more

Summer Fraud and Abuse Roundup

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

New Nondiscrimination Rules Impact Health Care Providers and Health Plans

Earlier this year, the Department of Health and Human Services (“HHS”) finalized regulations under Section 1557 of the Patient Protection and Affordable Care Act (the “ACA”). Section 1557 prohibits certain “covered entities”...more

New Federal Telemedicine Grants Announced; Florida Not Listed

The U.S. Department of Agriculture just announced new grant funding awarded to seven telemedicine and 11 distance learning projects across 16 states to use technology to expand access to health care, substance misuse...more

7th Cir. Demands Objective Standards in Whistleblower Complaint

On September 1 the Seventh Circuit affirmed dismissal of three of a whistleblower’s four fraud allegations against a mental health clinic, ruling that the allegations were based on the whistleblower’s subjective judgment...more

Strangest Regulatory Interpretation of the Month

The Massachusetts federal district court is hands-down winner of the August award for strangest regulatory interpretation of the month. The interpretation came in the context of denial of Omnicare’s summary judgment...more

CMS Lifts Temporary Suspension of Short Stay Reviews

Effective September 12, 2016, Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations (QIOs) resumed their hospital initial patient status reviews. The purpose of these reviews is to determine the...more

CMS's Payment Suspensions Wreak Havoc: Understanding the Risks

CMS payment suspensions can cripple any provider's or supplier's operations. Yet, CMS has the authority to impose a payment suspension upon the mere existence of "reliable information" that an overpayment or fraud may exist....more

Can a Relator Plead with Particularity without Alleging that a Patient’s Bill was Submitted to the Government?

The Seventh Circuit says yes. Early this month, the Seventh Circuit reversed and remanded a district court’s holding that a qui tam Relator failed to properly plead a False Claims Act suit where the Complaint did not allege...more

Nondiscrimination Standards Under ACA Section 1557: Now Is the Time to Act

Health insurers and group health plan sponsors must closely review the final rule titled “Nondiscrimination in Health Programs and Activities” (“Final Rule”) implementing Section 1557 of the Affordable Care Act (“ACA”) that...more

Client Alert: CMS to Physicians: QPP Reporting 2017 "Have it Your Way"

On August 8, 2016, the Centers for Medicare & Medicaid Services (“CMS”) announced in a blog post reminiscent of a Burger King commercial that physicians and other clinicians can indeed “have it their way” when reporting for...more

Federal Agencies Forced to Implement Huge Increases in Civil Monetary Penalties for Health Care Fraud

Thanks to section 701 of the Bipartisan Budget Act of 2015, Public Law 114–74, federal agencies have been forced to implement huge increases in penalties intended to deter health care fraud. The Federal Civil Penalties...more

Loaned and Awarded GME Slots: When does the three-year rolling average and the IRB ratio cap apply?

Ever since Congress capped teaching hospitals' Medicare-funded residency positions to the number of "full time equivalent" (FTE) allopathic and osteopathic residents the hospital reported in FY 1996, there have been very...more

Update on First 60-Day Case

A settlement was reached on August 23, 2016, in U.S. ex rel. Kane v. Healthfirst, Inc., et al., No. 11 CIV. 2325 (ER) (SDNY), a little over one year after the judge in that case issued the first judicial interpretation of the...more

Seventh Circuit Clarifies “Heightened” Pleading Standard for Fraud Claims under the False Claims Act

A recent decision of the United States Court of Appeals for the Seventh Circuit addressed the standard that courts should use to decide whether a whistleblower plaintiff has adequately pleaded that a defendant committed fraud...more

Obstruction of a Medicare Audit Doesn’t Require Direct Obstruction of a Federal Agent

A registered pharmacist, the owner of two Alabama pharmacies, pleaded guilty to obstructing a 2012 federal audit of Medicare claims and agreed to pay a $2.5 million penalty to the government. The submission of the false and...more

Raising Kane: CMS’s 60-Day Rule Commands More Than Treble Damages

In August 2015, we published a client advisory on the first judicial opinion interpreting the Affordable Care Act’s (ACA) “60-day overpayment rule,” which requires providers to “report and return” an overpayment of Medicare...more

First Circuit Adopts “Arm of the State” Test to Affirm Dismissal of FCA Complaint

In January 2016 in a matter of first impression, the First Circuit held that the University of Massachusetts Medical School is a state agency, and therefore not a “person” subject to liability in a False Claims Act (“FCA”)...more

Former Home Health Agency Owner Sentenced to 20 Years for $57MM Medicare Fraud

The US Department of Justice announced that Khaled Elbeblaswy, the former owner and manager three Miami-area home health agencies, was sentenced to 20 years in prison and ordered to pay $36.4 million in restitution for his...more

Compliance Concerns Raised Over Proposed Hospital Outpatient Department Rule

In an August 26, 2016, letter to the Centers for Medicare & Medicaid Services (CMS), the American Hospital Association (AHA) expressed serious concern over the portion of the calendar year 2017 hospital outpatient prospective...more

Health Law Pulse - September 2016

DOJ, NY AG REACH SETTLEMENT WITH HOSPITALS IN LANDMARK 60 - DAY RULE CASE - On August 24, 2016, the U.S. attorney for the Southern District of New York and the New York State attorney general announced a $2.95 million...more

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