There are a number of key issues that will drive the government’s enforcement efforts in the coming year and that will have a significant impact on how healthcare fraud matters are pursued by relators asserting FCA claims and are defended on behalf of healthcare providers. In the coming weeks, we will examine these issues in greater depth and why healthcare providers should keep a close eye on these issues. This week, we examine the government’s continued enforcement focus on long-term care providers.

The previous year saw the continued trend of an increasing number of FCA cases based on the theory that long-term care services (e.g., skilled nursing, home health, or hospice) provided to patients were medically unnecessary, and therefore, the healthcare provider submitted false claims in connection with those services.  See, e.g., U.S. ex rel. Hayward v. SavaSeniorCare, LLC, No. 3:11-cv-0821 (M.D. Tenn.), United States’ Consolidated Complaint in Intervention (Oct. 26, 2015); U.S. ex rel. HCR ManorCare, Inc., No. 1:09-cv-00013 (E.D. Va.), United States’ Consolidated Complaint in Intervention (April 10, 2015).

Continue Reading FCA Issues to Watch: Medical Necessity of Long-Term Care Services

For the first time in recent history, the previous year’s healthcare fraud headlines were noteworthy as much for legal developments and U.S. Department of Justice (DOJ) pronouncements as they were for the healthcare fraud recovery haul by the government.

To be sure, DOJ enjoyed yet another banner year of civil and criminal healthcare fraud enforcement results. During the fiscal year ending September 30, 2015 (FY 2015), the federal government racked up nearly $3.6 billion in civil fraud recoveries, marking the eleventh straight year in which such recoveries exceeded $1 billion.

Continue Reading A Look Back at Healthcare Fraud Enforcement Efforts from 2015

The FCA continues to be the federal government’s primary civil enforcement tool for investigating allegations that healthcare providers or government contractors defrauded the federal government. In the coming weeks, we will take a closer look at recent legal developments involving the FCA. This week, we examine the FCA’s public disclosure bar and recent cases considering whether disclosures are sufficient to bar FCA claims.

Courts have continued to clarify the requirements for a relator to be considered an original source, and thus exempted from the public disclosure bar, under the FCA’s pre-PPACA and post-PPACA versions. In these cases, courts have typically focused on the requirements that a relator have “direct and independent knowledge of the information on which the allegations are based” (pre-PPACA) and “knowledge that is independent of and materially adds to the publicly disclosed allegations or transactions” (post-PPACA).

Continue Reading FCA Deeper Dive: Original Sources under the FCA’s Public Disclosure Bar

The FCA continues to be the federal government’s primary civil enforcement tool for investigating allegations that healthcare providers or government contractors defrauded the federal government. In the coming weeks, we will take a closer look at recent legal developments involving the FCA. This week, we examine the FCA’s public disclosure bar and recent cases considering whether disclosures are sufficient to bar FCA claims.

The FCA’s public disclosure bar prevents a relator from filing a qui tam complaint based on information previously disclosed to the public, thereby dissuading parasitic lawsuits based on publicly available information. In cases considering the scope of the public disclosure bar, courts have continued to examine the issue of how or to whom information must be disseminated in order to constitute a “public disclosure,” which often has resulted in a narrowing of the public disclosure bar’s scope in a given case. Such cases marked a shift away from decisions favorable to FCA defendants toward a more nuanced and specific application of the public disclosure bar.

Continue Reading FCA Deeper Dive: When Public Disclosures Bar FCA Claims

Bass, Berry & Sims attorney Brian Roark was interviewed for an article in Becker’s Hospital Review and identified five trends that will impact False Claims Act (FCA) recoveries in 2016. Several case rulings from 2015 and a shift in government focus has the potential to allow for continued financial recoveries in the coming year, especially within the healthcare industry.

The five trends outlined in the article include:

  1. Use of extrapolation
  2. Focus on physician compensation
  3. Spotlight on individual liability
  4. Disclosure of overpayments
  5. Recognition of implied certification

The full article, “5 False Claims Act Trends, Cases that Will Fuel Recoveries in 2016,” was published by Becker’s Hospital Review on January 6, 2016.

There are a number of key issues that will drive the government’s enforcement efforts in the coming year and that will have a significant impact on how healthcare fraud matters are pursued by relators asserting FCA claims and are defended on behalf of healthcare providers. In the coming weeks, we will examine these issues in greater depth and why healthcare providers should keep a close eye on these issues. This week, we examine the future of implied certification as a viable FCA theory of falsity.

In December 2015, the U.S. Supreme Court granted the petition for writ of certiorari in Universal Health Services, Inc. v. Escobar and will consider whether and to what extent the implied certification theory is a viable theory of falsity under the FCA.  This case undoubtedly will be one of the most closely watched FCA cases to be argued before the Supreme Court since the 1986 amendments to the FCA.

Continue Reading FCA Issues to Watch: The Future of the FCA’s Implied Certification Theory of Falsity

Bass, Berry & Sims and the Tennessee Hospital Association recently sponsored the Nashville Healthcare Fraud Conference, a full-day seminar providing insight into fraud and abuse enforcement issues within the healthcare industry. Panel discussions were led by experienced counsel and government attorneys who offered insight into a variety of healthcare fraud and abuse topics, including:

  • Year in Review: Looking Back on Healthcare Fraud Issues in 2015
  • How Healthcare Organizations Prevent Whistleblowers
  • A Deeper Dive on Data Mining
  • Overpayments and Self Disclosures
  • Navigating Parallel Proceedings
  • Addressing Physician Compensation Issues in Due Diligence
  • Conducting Effective Witness Interviews
  • Anatomy of a Healthcare Fraud Investigation
  • Practical Tips for GCs: Managing Compliance Issues from the Client’s Perspective

Keynote remarks were offered by Kerry Harvey, U.S. Attorney for the Eastern District of Kentucky, who offered practical tips to healthcare providers navigating an increasingly challenging enforcement environment.

The Healthcare Fraud Conference Brochure and the 2015 Healthcare Fraud Conference Presentation are both available online.

Earlier this month, the U.S. District Court for the Middle District of Tennessee dismissed a relator’s qui tam lawsuit, finding that the relator had failed to adequately allege the presentment of false claims to the government. In U.S. ex rel. Prather v. Brookdale Senior Living, Inc., the relator alleged that Brookdale submitted false claims for home health services that did not meet the technical requirements for billing under Medicare rules and regulations. Defendants argued that the allegations failed to include sufficient detail regarding the actual submission of requests for anticipated payment (RAP) claims and that the relator failed to plead the requisite legal falsity of both RAP and final episode payment claims.

Continue Reading Middle District of Tennessee Clarifies Pleading Standards for the Presentment of False Claims

Earlier this year, Deputy Attorney General Sally Quillian Yates issued new guidance outlining the DOJ’s increased focus on individual accountability during civil and criminal investigations of corporate wrongdoing. The principles announced in the “Yates Memo” serve as the basis for revisions to the U.S. Attorney’s Manual – particularly the section outlining the Principles of Federal Prosecution of Business Organizations – released November 16, 2015. While many of the principles outlined in the Yates Memo and recent revisions to the U.S. Attorney’s Manual are consistent with DOJ’s prior practice and rhetoric regarding white collar investigations, the emphasis on individual accountability requires companies to consider carefully those aspects of an internal investigation with consequences on individual executives and employees.

Continue Reading The Yates Memo and Consequences for Internal Investigations

DOJ recently reached settlements in connection with three long running enforcement efforts, amassing more than $1 billion in settlement funds. These settlements reflect the continued expansion of aggressive government enforcement in the healthcare industry. Since January 2009, DOJ claims recovery of more than $16.2 billion in healthcare-related FCA cases alone.

Swiss pharmaceutical company Novartis AG agreed to pay $390 million to settle allegations that it provided unlawful rebates to specialty pharmacies to boost prescription refills for Novartis products. While Novartis did not admit that these rebates constituted illegal kickbacks, it did acknowledge providing rebates to three specialty pharmacies to incentivize an increase of prescription refills. This settlement comes at the conclusion of Novartis’ five-year CIA resulting from a settlement with DOJ in 2010. As part of its latest settlement, Novartis has agreed to extend its CIA for an additional five year period. Additionally, Novartis has agreed to amend its CIA to include obligations covering the company’s interactions with specialty pharmacies and to provide an annual report to DOJ detailing Novartis’ compliance with the CIA.

Continue Reading Recent FCA Settlements Bring Closure to Long Running Enforcement Efforts

From the Bass, Berry & Sims Blog Network
From the Bass, Berry & Sims Blog Network

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