News & Analysis as of

Medicare False Claims Act (FCA)

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

Electronic Health Records Vendor Agrees to $155 Million Settlement to Resolve FCA Allegations, Required to Make Free Upgrades to...

by King & Spalding on

On May 31, 2017, the DOJ announced a $155 million settlement with eClinicalWorks (ECW), one of the nation’s largest electronic health records (EHR) vendors, to resolve a False Claims Act lawsuit brought by a whistleblower. ...more

After Escobar, Lower Courts Build On The “Materiality” Analysis for False Claims Act Lawsuits

It’s been just over a year since the Supreme Court’s seminal False Claims Act (“FCA”) decision Universal Health Servs., Inc. v. United States ex rel. Escobar. In the wake of Escobar, the lower courts are confronted with...more

Genesis Healthcare Settlement with Federal Government

by Dorsey & Whitney LLP on

On June 16th, 2017, The Department of Justice (“DOJ”) announced a $53.6 million dollar settlement with Genesis Healthcare Inc. (“Genesis”) over six federal whistleblower lawsuits alleging that subsidiaries of the...more

OIG Reports More Than $731 Million in Inappropriate Medicare Meaningful Use Payments

by McDermott Will & Emery on

The Electronic Health Records (EHR) Incentive Program run by Centers for Medicare and Medicaid Services (CMS) garnered attention again last week following the release of a report by the Office of Inspector General of the US...more

Genesis Healthcare Enters $53.6 Million Settlement

by King & Spalding on

On June 16, 2017, the Department of Justice announced that Genesis Healthcare paid $53.6 million to resolve six False Claims Act whistleblower lawsuits filed by seven of Genesis’ former employees. The lawsuits alleged that...more

Court Puts the Brakes on Whistleblower's FCA Parking Claims

by Baker Ober Health Law on

The Department of Justice (DOJ) reports that, in fiscal year 2016 ending September 30, it obtained more than $4.7 billion in settlements and judgments from civil cases involving fraud and false claims. More than half of this...more

"Meaningfully Useful" Risk Mitigation Strategies for Providers Following the eClinicalWorks Settlement

by Jones Day on

The Health Information Technology for Economic and Clinical Health Act ("HITECH Act") established financial incentives under Medicare and Medicaid for eligible health care providers that adopt, implement, and demonstrate use...more

The Enforcement Risks for Medicare Advantage Plans Continue: A New False Claims Act Settlement in Florida

Recent activities of the Department of Justice (“DOJ”) and Qui Tam whistleblowers reveal that Medicare Advantage Plans remain at the forefront of investigations for violations of the federal False Claim Act (“FCA”) for...more

Reasonable Interpretation of Ambiguous Regulation May Not Preclude False Claims Act Liability

by Holland & Knight LLP on

A recent appellate court ruling governing all federal court cases in Florida, Georgia and Alabama establishes that a defendant in a False Claims Act (FCA) case cannot rely on a defense that there was no intent to defraud the...more

False Claims Act Settlement with eClinicalWorks Raises Questions for Electronic Health Record Software Vendors

by McDermott Will & Emery on

On May 31, 2017, the US Department of Justice announced a Settlement Agreement under which eClinicalWorks, a vendor of electronic health record software, agreed to pay $155 million and enter into a five-year Corporate...more

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