SCOTUS Decides Implied Certification Issue in Key False Claims Act (Whistleblower) Case

In a decision that is poised to have resonating implications for health services providers, the Supreme Court of the United States explicitly endorsed the “implied false certification theory of liability” under the False Claims Act (FCA) in Universal Health Services, Inc. v.  U.S. ex rel. Escobar.  Under this theory of liability, any person who submits […]

Billing Agent for Healthcare Provider Settles for $500,000 to Resolve TRICARE False Claims Act Case

Today, the Department of Justice U.S. Attorney’s Office for the Northern District of New York announced a settlement with Medical Reimbursement Systems, Inc. (“MRSI”) to resolve allegations that it violated the false claims act.  The press release can be found here. Medical Reimbursement Systems, Inc. provided billing, coding and full revenue cycle services for health care […]

Update: Court Denies Motion to Dismiss Federal Case and Identifies When 60-day Clock for Repayment of Overpayments Begins Ticking

On August 3, 2015, Judge D.J. Ramos of the Southern District of New York denied Healthfirst’s motion to dismiss the United States’ action under the False Claims Act (FCA) and the related state action.  Healthfirst contended in its motion that the government failed to sufficiently plead the case.  Notably, in denying this motion, the court […]

Medicare Reimbursement Standards Take Center Stage in Dismissal of False Claims Act Case

Our monthly Health Law Update from the Albany County Bar Association Newsletter has been released a few days early.  This month’s article discusses a Georgia federal court decision granting summary judgment to a nursing home and a rehabilitation therapy provider in a Federal False Claims Act prosecution that alleged the unnecessary provision of rehabilitation therapy services. Although the […]

SCOTUS Grants Cert in King v. Burwell

In what could be very important news this afternoon regarding the Patient Protection and Affordable Care Act (“PPACA,” or more commonly called “Obamacare”), the Supreme Court of the United States announced that it was granting certiorari in the case of King v. Burwell, decided on July 22, 2014, by the United States Court of Appeals […]

An Ever Widening Gap: Circuit Split on the Applicable Pleading Standard for the False Claims Act

Many areas of the False Claim Act are subject to legal interpretation and have been subject to Circuit splits, sometimes resulting in rulings from the Supreme Court.  In the United States, there are thirteen federal circuit courts that provide intermediate appellate review of the federal district courts in several states.  The decision by a circuit […]

Attention Medicaid and Medicare Providers: US DOJ Sues Providers for Failing to Return Overpayments Within 60 Days

On June 27, 2014, in the case of United States ex rel. Kane v. Healthfirst, Inc., et al., No. 11-2325 (S.D.N.Y.), the United States Department of Justice (USDOJ), via the United States Attorney’s Office for the Southern District of New York, sued several Medicaid providers under the federal False Claims Act for failing to return […]

Fourth Circuit Decision Addresses Constitutionality of Per-Claim Penalty under Federal False Claims Act

The decision delivered just before Christmas by the United States Court of Appeals for the Fourth Circuit in US ex rel. Kurt Bunk, et al., v. Gosselin Worldwide Moving, N.V., et al. is of value and of interest to all healthcare providers subject to the reach of the Federal False Claims Act (hereafter “FCA”). Although not […]

Ninth Circuit Court Rules Recovery Audit Contractor’s Decisions to Reopen Medicare Claims For Good Cause Can’t Be Challenged

Two weeks ago the U.S. 9th Circuit Court of Appeals ruled in Palomar Medical Center v. Sebelius that a health care provider is not entitled to challenge the determination of a Medicaid Recovery Audit Contractor (“RAC”) to reopen a Medicare claim for reimbursement for good cause. Palomar had provided inpatient rehabilitation services to a patient following […]

Ninth Circuit on HIPAA Criminal Liability: No Knowledge Requirement

On May 10, 2012, the United States Court of Appeals for the Ninth Circuit issued its opinion in United States v. Zhou, No. 10-50231 (9th Cir. May 10, 2012), and held that the criminal misdemeanor provision of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), located at  42 U.S.C. § 1320d-6(a)(2)—which penalizes the […]