News & Analysis as of

False Claims Act (FCA) Medicare

CMS Publishes RADV Medical Reviewer Guidance

by Dentons on

In the Medicare Advantage (MA) context, "risk adjustment" is the process by which the Centers for Medicare & Medicaid Services (CMS) reimburses Medicare Advantage Organizations (MAOs) based on demographic factors and the...more

Early Victory: Judge Dismisses Qui Tam Suit Against UnitedHealthcare

by Arnall Golden Gregory LLP on

On October 5, 2017, in United States of America ex rel. Swoben v. Scan Health Plan, et al. (“Swoben”), Judge John F. Walter of the United States District Court for the Central District of California granted United Health...more

Corporate Actors Held Individually Accountable in Recent False Claims Act Settlement

The Department of Justice (“DOJ”) has sent a clear message that individuals cannot hide behind the corporate shield in its recent settlement with Med-Fast Pharmacy, Inc. and the charges brought against its associated...more

Federal Court Strikes DOJ's Risk Adjustment False Claims Act Case - For Now

by Pepper Hamilton LLP on

On October 5, a federal district court in California dealt a significant setback to the government’s efforts to extend False Claims Act (FCA) liability to Medicare risk adjustment submissions....more

False Claims Act Watch: California Federal Judge Dismisses DOJ Complaint Alleging Medicare Advantage Fraud

by Kelley Drye & Warren LLP on

On October 5, the U.S. Department of Justice suffered a setback when a California federal judge dismissed its complaint under the civil False Claims Act (“FCA”). Billed as a test case for the Government, it marked the first...more

Alert: In a Surprise Decision Issued on October 5, 2017, Honorable John Walter, United States District Judge, Dismissed a Medicare...

On October 5, 2017, the Honorable Judge John Walter of the United States District Court, Central District of California, granted the Defendants’ Motion to Dismiss the Medicare Advantage (“MA”) Federal False Claims Act (“FCA”)...more

Newly Announced Chicago Health Care Fraud Unit Could Signal a Change in the Northern District of Illinois’s Health Care...

by Ropes & Gray LLP on

On July 18, 2017, Acting U.S. Attorney for the Northern District of Illinois, Joel R. Levin, announced the creation of a dedicated criminal Health Care Fraud Unit. The five prosecutor unit will operate within the Criminal...more

Finally, Recovery of Attorney Fees for Government Overreach

by Faegre Baker Daniels on

There are two major, interrelated reasons why government contractors, including Medicare providers, are so afraid of the False Claims Act (FCA). One is the draconian nature of the liability: treble damages plus up to $21,916...more

Maybe the Yacht Was the Tip-Off

by Faegre Baker Daniels on

If you’re a surgical device distributor and you want to reward a surgeon for using your products on Medicare and Medicaid patients, you may want to choose a reward that’s less conspicuous than a yacht. That’s one lesson in...more

Holding Executives Personally Responsible: An Increasing Government Priority

by McGuireWoods LLP on

Earlier this month, we covered the Spectocor action which involved an executive and his company’s agreement to pay $10.56M of a $13.45M total settlement to resolve allegations involving medically unnecessary Medicare...more

Healthcare Law Update: September 2017

by Holland & Knight LLP on

OIG Advisory Opinions - Manufacturer's Free Replacement of Spoiled Pharmaceutical Products Authorized - On Aug. 25, 2017, the U.S. Department of Health and Human Services' (HHS) Office of Inspector General (OIG)...more

Second Circuit Accepts Appeal of False Claims Act First-To-File Issues

by Farrell Fritz, P.C. on

The Second Circuit recently agreed to accept an interlocutory appeal to decide the question whether a violation of the False Claims Act’s “first-to-file” rule compels dismissal of the complaint or whether it can be cured by...more

Reminder: Medical Providers Must Be Attentive to Credit Balances and Other Overpayments

It has now been a number of years since the enactment of Section 6402(a) of the Affordable Care Act ("ACA"), which requires among other things that any recipient of a Medicare or Medicaid overpayment report and return it...more

Bad News for Whistleblowers: Defendant Pleads Guilty

by Faegre Baker Daniels on

At first glance, it looks nonsensical. How could it be bad news for False Claims Act whistleblowers that the defendant pleaded guilty to violating that statute—to committing the very Medicare fraud the whistleblowers alleged?...more

Physicians Maintain High Standards

by Burr & Forman on

By the time this article goes to print, a lot could change, so there’s no apparent use in guessing what will come of the next Repeal and Replace efforts or what’s happening at Main Justice. Nobody knows. The only certainties...more

340B Covered Entities Beware: CMS Proposes Drastic Drug Reimbursement Rate Cuts

by Polsinelli on

In its Outpatient Prospective Payment System proposed rule ("Proposed Rule"), CMS outlined a significant Medicare Part B payment reduction for separately payable, nonpassthrough drugs provided in the hospital outpatient...more

Sixth Circuit: Technical Physician Signature Deficiencies not "Material" to Reimbursement Claims

by Jones Day on

The District Court for the Middle District of Tennessee held on June 22, 2017, that the timing requirements related to a physician's certification of need for home health services were not "material" to the Centers for...more

Yates Memo's Influence Felt in DOJ Health Care Enforcement

by Jones Day on

In September 2015, Deputy Attorney General Sally Yates issued a memorandum titled "Individual Accountability for Corporate Wrongdoing." In it, she stressed that one of the most effective ways to combat corporate misconduct is...more

Medicare Fraud Strike Force Strikes Again – in a Big Way

The Medicare Fraud Strike Force initiated its largest ever healthcare enforcement action, charging 412 defendants in July 2017 with approximately $1.3 billion in fraudulent claims. The Strike Force consists of teams that...more

Recent Department of Justice Crackdown on Fraud and Abuse

As reported by the New York Times in an article dated July 13, 2017, in an effort to crack down on fraud and abuse, and with a particular focus on opioids, the Department of Justice (“DOJ”) is charging 412 individuals for...more

Client Alert: Feds Shine a Light on Medicare Advantage Plans and Physicians Related to Risk Adjustment Practices

Although the sufficiency of medical records documentation supporting beneficiary diagnoses for Medicare Advantage (MA) risk adjustment has been on the OIG’s work plan since 2013, the Department of Justice has upped the ante...more

Escobar case limits False Claims Act liability for providers

by Thompson Coburn LLP on

Health care providers, as government contractors, must make certain representations of fact when submitting claims for government program reimbursement, such as Medicare. Sometimes through no fault of the contractor, such...more

Amounts Billed Do Not Indicate Fair Market Value In FCA Case

by Reed Smith on

Our day job has been keeping us busy, so busy with depositions, motions, delayed flights, and assorted drama that we have not posted in more than a month. After such a long layoff, we had hoped to return with a vengeance, a...more

Court Overreaches in Requiring Medical Necessity Determination by Labs

by Jones Day on

On June 9, 2017, the U.S. District Court for the District of Columbia denied a motion to dismiss brought by a laboratory in U.S. ex rel. Groat v. Boston Heart Diagnostics Corp., 2017 WL 2533341. Part of the grounds for...more

The Circuits are Split: The Ambiguity of a Regulation May Not ‘Foreclose a Finding of Scienter’ in False Claims Act Cases

by K&L Gates LLP on

A split now exists among the circuit courts as to whether a defendant’s assertion of a “reasonable interpretation defense” precludes a finding of a “knowing” mens rea under the False Claims Act (the “FCA”). On May 26, 2017,...more

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