Medicaid Fraud

Medicaid is a partnership program between states and the federal government to provide healthcare coverage for lower income individuals, people with disabilities, older people, and certain families with... more +
Medicaid is a partnership program between states and the federal government to provide healthcare coverage for lower income individuals, people with disabilities, older people, and certain families with children.  less -
News & Analysis as of

OIG Releases FY 2016 Statistical Data About Medicaid Fraud Control Units

Earlier this week, the Office of Inspector General for the Department of Health and Human Services (“OIG”) posted its fiscal year (“FY”) 2016 data about Medicaid Fraud Control Units (“MFCUs”) across the country....more

This Month in Corruption: the Same Old Saga Continues

As a faithful reader of the State House News Service, I have been noticing for years how often the Press Releases section of the service’s subscriber-only web site contains an account of wrongdoing and/or unsavory behavior in...more

2016 Nerve-of-a-Burglar Award

Competition for the 2016 Nerve-of-a-Burglar Award was fierce, with health care providers constantly coming up with new and different ways to scam Medicare and Medicaid. Nevertheless, we have a clear winner: the Michigan...more

This Month in Corruption: Snapshots of the Public Trust Betrayed

If I were back in the newspaper business, I’d probably write a lead for this article with the cliché that “crime never takes a holiday.” Yes, clichés are the first resort of lazy scribes, but the good thing is, they are...more

Universities Are Prime Targets for False Claims Act Liability

Colleges and universities receive billions of dollars in federal funds, whether through research grants or student financial aid, or even by billing Medicare or Medicaid for services rendered at academic medical centers. As a...more

OIG “Investigative Advisory” Highlights Potential Medicaid Fraud, Patient Harm Stemming from Personal Care Services

The OIG has issued an “Investigative Advisory on Medicaid Fraud and Patient Harm Involving Personal Care Services” that identifies various “fraud schemes” it has encountered involving personal care services (PCS) — nonmedical...more

Tenet Healthcare Settles Fraud Case for $514 Million

If you work in compliance in the healthcare industry, you have a tough job. The number and variety of risks that healthcare providers face is daunting. The False Claims Act is a mighty weapon in the hands of federal...more

CMS and OIG Propose First Major Medicaid Fraud Control Program Changes Since 1978

On September 20, 2016, CMS and the OIG jointly published a proposed rule, available here, to amend the largely unchanged 1978 regulation governing State Medicaid Fraud Control Units (MFCUs). Since the initial issuance of the...more

HHS Proposes Changes to State Medicaid Fraud Control Unit Rules

The Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) have proposed amendments to the regulations governing State Medicaid Fraud Control Units (MFCUs). The proposed rule would reflect...more

What’s In a Name? Or, the Importance of Emphasis

I.A. Khair of New Jersey ran an ambulance company called K&S Invalid Coach. Presumably, “Invalid” was pronounced IN-va-lid, with the emphasis on the first syllable. Maybe it should have been pronounced in-VAL-id, with the...more

Materiality Is the New Condition of Payment: The Implied False Certification Theory After Escobar

The Supreme Court has made it clear that, even at the pleadings stage, relators (or the government) must plead facts to support materiality with plausibility and particularity. For False Claims Act (FCA) defendants who...more

SCOTUS Gives Fed Contractors Mixed Bag

Last week the U.S. Supreme Court issued an opinion that refines and re-defines liability for contractors accused of defrauding the Federal Government under the False Claims Act (“FCA”) in Universal Health Services, Inc. v....more

Supreme Court ruling potentially expands false claims liability for healthcare providers

In a much-anticipated decision, the U.S. Supreme Court ruled recently that the implied false certification theory may form the basis for liability under the False Claims Act (FCA), resolving a split of among the federal...more

Supreme Court Case Expands False Claims Act Liability

Summary of Decision - On June 16, 2016, the United States Supreme Court decided a case which could have significant impact on healthcare providers. In Universal Health Services Inc. v Escobar, the Court expanded...more

Universal Health Services v. Escobar

On Thursday of last week, the Supreme Court for the first time addressed the “implied certification” theory of liability under the False Claims Act. The Court ruled unanimously that the theory is valid in certain...more

Supreme Court Adopts Implied False Certification Theory in Universal Health Services v. United States ex rel. Escobar But Imposes...

On June 16, 2016, a unanimous Supreme Court issued its long-awaited decision in Universal Health Services v. United States ex rel. Escobar (“Escobar”). The Court ruled that under certain circumstances the theory of “implied...more

"In Escobar, Supreme Court Upholds False Claims Act’s Implied Certification Theory"

On June 16, 2016, the U.S. Supreme Court in Universal Health Services v. United States ex rel. Escobar unanimously upheld the implied certification theory of False Claims Act (FCA) liability. The Court ruled that a party can...more

The Supreme Court Adopts Broad Scope of False Claims Act Liability

A unanimous Supreme Court issued its long-awaited and closely watched decision today on the scope of the False Claims Act (“FCA”), and the Court affirmed the FCA’s long reach. Universal Health Services, Inc. v. United States...more

Pennsylvania’s Proposed False Claims Act: Why Further Incentivizing Whistleblowers Is Unnecessary, Counterproductive, and Could...

As Pennsylvania legislators work to resolve the budget impasse, proponents of enacting a Pennsylvania False Claims Act (“PA FCA”) targeting Medicaid continue to intensify their efforts in Harrisburg. Legislators may consider...more

Foreign Corrupt Practices Act 2015 Update

Despite a decline in enforcement actions by the Securities Exchange Commission (“SEC”) and the Department of Justice (“DOJ”), the first half of 2015 has continued to highlight the relevance and ever-evolving effects of the...more

State Pharmaceutical Pricing Disclosure Laws: Old Story, New Refrain

As a veteran of the AWP litigation era, I am struck by the recent state efforts to legislate transparency into pharmaceutical pricing. Multiple states have introduced bills that would require pharmaceutical manufacturers to...more

Washington Healthcare Update

This Week: FDA Begins Device User Fee Talks with Patients and Consumers Sept. 15... CMS Extends Partial Enforcement Delay of Two-Midnight Policy Through 2015... Alaska Legislature Sues Governor Over Medicaid Expansion....more

Criminal Prosecutions of Health Care Fraud: The Stakes Continue to Rise for Individual Providers

On June 18, 2015, the U.S. Department of Justice (DOJ), in collaboration with the U.S. Department of Health and Human Services (HHS), announced criminal charges against 243 individuals located in 14 states for various health...more

Reverse Payment Settlements as Basis for False Claims Act Liability

The threat of federal False Claims Act (“FCA”) liability based on the failure to promptly return overpayments is a relatively new phenomenon, but it is receiving a lot of attention. In 2009, Congress enacted the Fraud...more

Wisconsin Repeals State False Claims Act

On July 12, 2015, the state of Wisconsin passed a budget that, along with many expected cuts, additions, and tweaks, unexpectedly repealed Wisconsin’s False Claims for Medical Assistance Act—the state’s version of the federal...more

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