Seventh Circuit Says “Medical Necessity” FCA Claims Require Specifics

Posted on September 7, 2016 in Rule 9(b)

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Written by: David B. Honig

Last week, the Seventh Circuit Court of Appeals handed down its decision in  US ex rel. Presser v. Acacia Mental Health Clinic, LLC. [1] The FCA case was brought by a nurse practitioner whistleblower who alleged that services being provided were not medically necessary. The court affirmed dismissal under Rule 9(b)... Continue Reading →

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Government Challenges “Materiality” Standard of Escobar

Posted on September 6, 2016 in False Certification, Government Intervention

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Written by: Benjamin Waters

Ever since the Supreme Court’s June 16, 2016 decision in Universal Health Services, Inc. v. United States ex rel. Escobar, a False Claims Act (“FCA”) case upholding the theory of implied certification, significant discussion has commenced regarding the Court’s “new” FCA materiality standard. How the appellate courts define materiality under... Continue Reading →

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9th Circuit Issues Blockbuster Medicare Advantage FCA Decision

Posted on August 11, 2016 in False Certification, Rule 9(b)

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Written by: David B. Honig

The 9th Circuit Court of Appeals just issued a blockbuster ruling in U.S. ex rel. Swoben v United Healthcare et al., ruling that United Healthcare, WellPoint, Aetna and other major health insurance providers must answer to a whistleblower’s complaint that they defrauded the Medicare Advantage program. The Medicare Advantage Program,... Continue Reading →

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Massive Penalty Spike Darkens the FCA Landscape

Posted on June 30, 2016 in Case Analysis, Damages, Statutes and Regulations

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Written by: David Honig

In November 2015, the Bipartisan Budget Act of 2015 went into effect. One aspect of that act was the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015. The new law required that the Program Fraud Civil Remedies Act and the False Claims Act (“FCA”) penalties be “corrected” to... Continue Reading →

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Supreme Court Accepts Implied Certification – With a Twist

Posted on June 16, 2016 in Case Analysis, False Certification

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Written by: David B. Honig

The U.S. Supreme Court issued its decision today in Universal Health Services, Inc. v. United States ex rel. Escobar, and it will have an enormous effect on False Claims Act (“FCA”) cases throughout the nation. In Escobar, the FCA case was based upon the theory that counseling was provided by practitioners... Continue Reading →

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7th Circuit Rules “Usual and Customary Pricing” Can Include Discount Programs

Posted on May 31, 2016 in Case Analysis, Materiality, Pharmacy

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Written by: David B. Honig

A recent whistleblower case could have a significant impact on Medicare Part D charge limits and corresponding reimbursement and could have ripple effects for aspects of other Medicare programs. The Seventh Circuit Court of Appeals ruled that reduced prescription prices offered by a large retail pharmacy (here Kmart) to participants enrolled... Continue Reading →

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Enforceability of FCA Releases Questioned

Posted on May 30, 2016 in Case Analysis, Employment, Release

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Written by: David B. Honig

Releases of FCA claims my only be effective in very limited circumstances, the Second Circuit Court of Appeals ruled in a decision this week. In US ex rel. Ladas v. Exelis, Inc, et al., the court ruled that a pre-filing release is unenforceable as a matter of public policy –... Continue Reading →

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Massive Spike in FCA Penalties

Posted on May 4, 2016 in Damages, Retained Overpayments, Settlement, Statutes and Regulations

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Written by: David B. Honig

In November 2015, the Bipartisan Budget Act of 2015 went into effect. One aspect of that act was the Federal Civil Penalties Inflation Adjustment Act Improvements Act of 2015. The new law required that the Program Fraud Civil Remedies Act and the False Claims Act (“FCA”) penalties be “corrected” to adjust... Continue Reading →

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Government Approval and Percentage in FCA Cases

Posted on April 6, 2016 in Case Analysis, Settlement

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Written by: David B. Honig

An Indiana Federal District Court just published an opinion on an issue of first impression in the Seventh Circuit, the ability of the government to reject or approve a settlement in a case in which they did not intervene. The court also opined on the ability of a whistleblower to... Continue Reading →

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Sixth Circuit Rejects HITECH FCA Complaint

Posted on March 14, 2016 in False Certification, Regulatory Noncompliance

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Written by: David B. Honig

The Sixth Circuit Court of Appeals, in US ex rel. Sheldon v. Kettering Health Network, affirmed the dismissal of a False Claims Act (“FCA”) suit alleging fraud based upon certifications of compliance with the HITECH Act and a data breach. The HITECH Act, or Health Information Technology for Economic and Clinical... Continue Reading →

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