In a recent decision, U.S. ex rel. Sibley v. Univ. of Chicago Medical Center, the U.S. Court of Appeals for the Seventh Circuit considered allegations that two medical billing and debt collection companies, Medical Business Office Corp. (MBO) and Trustmark Recovery Services, Inc. (Trustmark), and the University of Chicago Medical Center (UCMC), a client of one of the debt collection companies, violated the False Claims Act (FCA) by seeking inappropriate reimbursement from the Centers for Medicare and Medicaid Services (CMS) for Medicare “bad debts.”
Continue Reading Seventh Circuit Signals Ongoing Importance of Compliance with Medicare “Bad Debt” Regulations
False Claims Act Fundamentals: Anti-Kickback Statute and the Stark Law
As previous False Claims Act (FCA) Fundamentals posts have discussed, the FCA, 31 U.S.C. § 3729, et seq., can be triggered by submitting claims tied to violations of certain federal statutes. This post will explain the basics of two such statutes: the Anti-Kickback Statute (AKS) and the Stark Law.
Continue Reading False Claims Act Fundamentals: Anti-Kickback Statute and the Stark Law
DOJ’s Civil Cyber-Fraud Initiative Impact on Healthcare Organizations
Recently, I was interviewed on the Healthcare Strategies podcast about how the Department of Justice (DOJ) is enforcing the Civil Cyber-Fraud Initiative to hold healthcare organizations accountable for cybersecurity matters.
Continue Reading DOJ’s Civil Cyber-Fraud Initiative Impact on Healthcare Organizations
Fifth Circuit Affirms Criminal Healthcare Fraud Convictions of Hospice and Home Health Executives
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, the defendants operated a “reimburse-first-verify-later system” for nearly ten years, under which an estimated 70 to 85 percent of patients were ineligible for the care they received. The Fifth Circuit provided colorful examples to show that “many certifications were not borderline cases”:
Continue Reading Fifth Circuit Affirms Criminal Healthcare Fraud Convictions of Hospice and Home Health Executives
The California Insurance Frauds Prevention Act: What to Know About California’s Powerful Commercial Health Insurance Fraud Statute
Although this blog focuses mainly on the federal False Claims Act (FCA), other antifraud statutes feature in the qui tam relator and government enforcement toolkit. Key among them: the California Insurance Frauds Prevention Act (IFPA).
Continue Reading The California Insurance Frauds Prevention Act: What to Know About California’s Powerful Commercial Health Insurance Fraud Statute
False Claims Act Cases in Home Health Sector
I recently discussed the trends related to False Claims Act (FCA) settlements in the home health sector, as revealed in the Healthcare Fraud & Abuse Settlements Database which we launched earlier this year. The database was part of the comprehensive Healthcare Fraud & Abuse Resource Center that provides an overview of FCA enforcement settlements, court decisions, updates involving the Stark Law and Anti-Kickback Statute, and other developments affecting the healthcare industry.
“We wanted to create a database of False Claims Act settlements to allow providers to have easy access to information, to see the cases that the government or regulators have resolved in the health care fraud space,” I told Home Health Care News. “This is the first publicly available database of this type.”
According to the information in the database, home health providers have paid at least $422.6 million since 2012 to settle FCA allegations. This represents 51 different cases over the time period from 2012-2020.
Continue Reading False Claims Act Cases in Home Health Sector
Provider Beware: Recent FCA Cases Emphasize the Importance of Diligently Addressing Potential Overpayments
A common feature of False Claims Act (FCA) litigation is the pursuit of liability under the FCA’s so-called “reverse” false claims provision, 31 U.S.C. § 3729(a)(1)(G). Reverse false claims liability applies when a person or entity knowingly does either of the following:
- Makes, uses, or causes, to be made or used, a false record or statement material to an obligation to pay or transmit money or property to the government.
- Conceals or knowingly and improperly avoids or decreases an obligation to pay or transmit money or property to the government.
The reverse false claims provision of the FCA is especially significant for healthcare providers, in part because the 2010 Affordable Care Act (ACA) (as well as associated regulations) expressly linked the knowing retention of overpayments from federal healthcare programs to reverse false claims liability under the FCA. Specifically, the relevant statutory provision of the ACA defines the term “obligation,” as used in the FCA, to include any overpayment that is not “reported and returned” within 60 days after it is “identified,” a term courts and Centers for Medicare & Medicaid Services (CMS) have interpreted somewhat broadly. See 42 U.S.C. § 1320a-7k(d). Thus, by “improperly avoid[ing]” this “obligation”—i.e., knowingly or recklessly failing to return the overpayment within the ACA’s 60-day timeframe—a provider violates the FCA.
The upshot for providers is that a failure to diligently investigate and appropriately address a potential overpayment may lead to a host of problems, including whistleblower lawsuits, intrusive government scrutiny, and ultimately, FCA liability for treble damages and civil penalties. What’s more, this may be true even in cases where the receipt of the overpayment was not itself the result of any fraudulent conduct. Indeed, as the cases discussed below demonstrate, that risk is far from just hypothetical.
The Eliminating Kickbacks in Recovery Act: An Unprecedented Expansion of Anti-kickback Liability to Private-Pay Referrals?
A recent piece of federal legislation intended to address the opioid crisis across the United States may have some unintended consequences. In attempting to prohibit “patient brokering” in the narrow context of addiction treatment and recovery centers, Congress may have unwittingly passed an unprecedented expansion of federal prosecutorial authority over payment arrangements between providers and referral sources for private-pay patients. For the reasons discussed in this blog post, any individual or entity who provides services relating to addiction treatment or recovery (as well as all clinical laboratories, regardless of whether they provide any addiction treatment or recovery services) should examine their arrangements with all referral sources for private-pay patients, even those who do not refer patients for addiction treatment or recovery services.
On October 24, 2018, the President signed into law the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (the “SUPPORT Act”), as discussed here. The SUPPORT Act consolidated a number of opioid-related bills, including the Eliminating Kickbacks in Recovery Act of 2018 (EKRA), which was intended to address the problem of “patient brokering” in the context of treatment centers and sober homes.
Brian Roark Comments on Government’s Declination to Intervene in Heartland FCA Case
Bass, Berry & Sims Healthcare Fraud & Abuse attorney Brian Roark provided a comment to Home Health Care News about the government’s decision not to intervene in the False Claims Act (FCA) case brought against HCR Manor Care’s hospice division, Heartland. In the case, a whistleblower accused Heartland of submitting false claims and statements to Medicare. However, as Brian points out in the article, Heartland isn’t “necessarily out of the woods yet; the government declining to intervene doesn’t mean an FCA case won’t go forward.”
Continue Reading Brian Roark Comments on Government’s Declination to Intervene in Heartland FCA Case
DOJ Intervention in Healthcare Fraud Case Highlights Potential Risks for Private Equity Firms
The Department of Justice’s recent decision to intervene in a False Claims Act case against not only a compounding pharmacy but also the private equity firm that owns a controlling stake in it, underscores the potential risks private equity firms face when operating in the highly regulated healthcare space. On February 16, 2018, the United States filed a complaint in intervention in Medrano v. Diabetic Care Rx, LLC, Case No. 15-62617-CIV-BLOOM, alleging the compounding pharmacy, Patient Care America (“PCA”), paid illegal kickbacks to marketing firms who targeted military members and their families for prescriptions for compounded drugs the pharmacy then created not to meet individual patient needs, but rather to maximize reimbursement from Tricare, the federal military health care program. In a somewhat unique move, the government also named as a defendant the private equity company Riordan, Lewis & Haden Inc. (“RLH”), which manages and controls PCA through a general partner.
Continue Reading DOJ Intervention in Healthcare Fraud Case Highlights Potential Risks for Private Equity Firms