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Lindsey Fetzer, a member in the Washington, D.C. office, represents clients in connection with government and internal investigations and litigations involving alleged violations of the False Claims Act (FCA), Anti-Kickback Statute (AKS), Foreign Corrupt Practice Act (FCPA), and other criminal and civil regulations. Lindsey has represented clients in foreign and domestic matters involving the U.S. Department of Justice (DOJ), U.S. Securities and Exchange Commission (SEC), and other primary enforcement agencies.

We have previously discussed the California Insurance Frauds Prevention Act (IFPA)–a state antifraud statute that, while modeled on the False Claims Act (FCA), is unique in targeting fraud in the commercial health insurance space.Continue Reading The California Insurance Frauds Prevention Act: Recent Developments Regarding California’s Powerful Commercial Health Insurance Fraud Statute

Last week, the U.S. Department of Justice (DOJ) announced a $22.4 million settlement resolving allegations that Martin’s Point Health Care, Inc. (Martin’s Point) violated the False Claims Act (FCA) by submitting inaccurate diagnosis codes for its Medicare Advantage Plan enrollees.  Continue Reading Martin’s Point Health Care Inc.’s $22.4M Settlement Illustrates DOJ’s Focus on Part C Fraud

On December 14, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that contemplates several changes to, and clarifications of, guidance for the Medicare Advantage (MA) program in coverage year 2024.

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On November 14, Judge Edward Chen in the Northern District of California issued rulings on the pending motions to dismiss in U.S. ex rel. Osnek v. Kaiser Permanente, granting in part and denying in part Kaiser’s motion to dismiss.
Continue Reading Judge Chen’s Message to Medicare Advantage Providers: ICD Guidelines Aren’t Suggestions

In a decision issued on September 30, Judge Andrew Carter of the U.S. District Court for the Southern District of New York denied Anthem Inc.’s motion to dismiss a government lawsuit filed in March 2020 claiming Anthem submitted inaccurate diagnosis data in conjunction with its Medicare Part C plans that resulted in alleged overpayments in violation of the False Claims Act (FCA).
Continue Reading SDNY Ruling in Anthem Sends a Signal to Medicare Advantage Litigants

In a September 2022 filing in U.S. ex rel. Osinek v. Kaiser Permanente, the Kaiser Permanente consortium defendants (Kaiser) highlighted the distinction between clinically inaccurate diagnoses (factual falsity) and clinically accurate but incorrectly coded diagnoses (legal falsity) and its relevance in False Claims Act (FCA) actions.
Continue Reading Medicare Advantage Plan Highlights Distinction for FCA Purposes between Clinically Inaccurate Diagnoses and Clinically Accurate Diagnoses that Allegedly Violate Subregulatory Guidelines

As developments related to COVID-19 continue to unfold, Bass, Berry & Sims attorneys are monitoring the situation and providing guidance through a series of video chats entitled, “COVID-19 Compliance Conversations.”

In this episode, Lindsey Fetzer and John Kelly provide a brief overview of compliance considerations related to conducting internal investigations remotely. Watch the video

Despite the mounting pressures on healthcare entities related to the COVID-19 (coronavirus) pandemic and recent announcements of regulatory waivers and flexibility in particular areas, regulators are still showing interest in the enforcement of federal requirements for life safety and emergency and infectious disease control preparedness for long-term care facilities.

OIG Medicaid Nursing Home Life Safety and Emergency Preparedness Reviews

On March 23, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) updated its Work Plan in response to the COVID-19 pandemic. Please see this post for more information about all of the OIG Work Plan updates. One of the areas that the OIG Office of Audit Services will focus on is Medicaid Nursing Home Life Safety and Emergency Preparedness Reviews.

OIG’s rationale for focusing on this is, in part, because the patient population in long-term care (LTC) facilities is especially vulnerable to COVID-19 and other disease outbreaks. The focus of the audit is LTC facilities’ compliance with federal requirements for life safety and emergency preparedness, as well as 2019 Centers for Medicare & Medicaid Services (CMS) expanded guidance on emerging infectious disease control.Continue Reading Increased Oversight of Long-Term Care Facilities Related to COVID-19

The financial relief programs enacted by the Coronavirus Aid, Relief, and Economic Security (CARES) Act stand ready to provide crucial financial support to people and businesses impacted by the novel coronavirus (COVID-19) pandemic and the resulting economic downturn.   These new federal programs recognize the scale of the challenges presented by the COVID-19 outbreak.

While decisions made by companies seeking CARES Act or similar relief may not be scrutinized today, we are likely to see a wave of COVD-19-related criminal and civil enforcement actions in the coming months and years.  Impacted individuals and businesses should remember that the urgent need for relief does not eliminate the importance of compliance or the likelihood of significant regulatory oversight in the future.

More specifically, applicants for CARES Act relief must certify or attest to certain facts relevant to their eligibility to participate in the CARES Act’s various programs.  Because false certifications or attestations potentially expose an applicant to liability under the federal False Claims Act (FCA), it is critical that impacted individuals and entities take reasonable steps to ensure the accuracy of information and certifications contained in any applications for federal aid.Continue Reading The CARES Act and Risk of FCA Exposure