Hospice Audit Series: The Second Guessing of Billed Hospice Physician Visits
Ever since utilization review (UR) became a mandatory requirement for all medical treatment requests, there have been numerous attempts to challenge not only individual UR determinations and the timeframes in which they have...more
Last month, a three-judge panel in the Ninth Circuit reversed the Northern District of California’s ruling in Wit v. United Behavioral Health. In Wit, the district court ruled that United Behavioral Health (“UBH”) breached...more
On March 24, the U.S. Court of Appeals for the Fifth Circuit affirmed the criminal healthcare fraud convictions of two individuals who ran a network of home health and hospice centers in Texas. According to the Fifth Circuit,...more
In Lyn M. v. Premera Blue Cross, 2020 U.S. App. LEXIS 23395 (10th Cir. July 24, 2020), the Tenth Circuit held that a district court had applied the wrong standard of review and incorrectly evaluated an ERISA plan...more
In this week’s episode, Gary Qualls discusses a recent case decided in the Western District of Louisiana, which highlights how the application of the arbitrary and capricious standard as applied to payor coverage...more
On September 13, 2019, the Ninth Circuit heard oral argument in the False Claims Act Case of Winter v. Gardens (18-55020). The government, as an amicus in the case, carried the bulk of the argument on behalf of the plaintiff...more
A new federal court decision offers a ray of light to those providers defending false claims actions based on an alleged lack of medical necessity. On September 9, 2019, the United States Court of Appeals for the Eleventh...more
In recent years, healthcare providers have increasingly faced civil and criminal enforcement actions premised on the allegation that services billed to government healthcare programs were not medically necessary. As a result,...more