On January 12, 2017, the Department of Health and Human Services Office of Inspector General (“OIG”) published the “Health Care Programs: Fraud and Abuse; Revisions to the Office of Inspector General’s Exclusion Authorities” Final Rule (“Final Rule”) revising and expanding its authority to exclude individuals and entities from participation in... Continue Reading →Tags: Abuse, ACA, Affirmative, Affordable Care Act, Authority, Changes, DOJ, Early reinstatement, Exclusion, Expand, False Claims Act, FCA, Final Rule, fraud, HHS, OIG, Permissive, regulation, Reinstatement, Revisions, update
On October 24, the Department of Justice (“DOJ”) announced a $145 million False Claims Act settlement with a national skilled nursing facility provider that operates more than 200 skilled nursing facilities (the “Company”) and its individual owner. The settlement has been touted as the largest in the DOJ’s history with a skilled nursing facility... Continue Reading →Tags: False Claims Act, FCA, nursing home, Skilled Nursing Facility, SNF
In light of the Supreme Court’s recent decision in Universal Health Services v. Escobar, the Seventh Circuit revisited its prior ruling in United States ex rel. Nelson v. Sanford-Brown, Ltd, a case alleging that a college receiving federal subsidies violated the False Claims Act (“FCA”) by maintaining discriminatory recruiting and... Continue Reading →Tags: certification, Escobar, False Claims Act, FCA, implied
In United States of America and the State of Florida, ex rel. Bingham v. HCA, Inc., the employee of a medical office building management firm filed suit against a national health care system in the U.S. District Court for the Southern District of Florida. The lawsuit included allegations relating to... Continue Reading →Tags: discovery, False Claims Act, FCA, motion to dismiss
The Eighth Circuit Court of Appeals yesterday applied the materiality standard enunciated by the Supreme Court in Universal Health Services, Inc. v. United States ex rel. Escobar to a False Claims Act (“FCA”) case alleging fraudulent inducement. In United States ex rel. Miller v. Weston Educational Inc., d/b/a Heritage College, two whistleblowers alleged Heritage College... Continue Reading →Tags: Escobar, False Claims Act, Heritage College, materiality, Weston Educational
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 →Tags: Acacia, False Claims Act, FCA, fraud with particularity, medical necessity, Presser, reasonable and necessary
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 →Tags: Escobar, false certification, False Claims Act, FCA, government, implied certification, Marsteller, material, materiality, Tilton, Universal Health Services
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 →Tags: certificaiton, False Claims Act, FCA, Medicare Advantage, Medicare Part C, Swoben, United Healthcare
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 →Tags: adjustment, Department of Justice, False Claims Act, FCA, fines, government, inflation, maximum, minimum, penalties
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 →Tags: False Claims Act, FCA, Garbe, Kmart, pricing, usual and customary