DOJHealth care providers will often try to negotiate and receive fair, commercially reasonable business terms with vendors and suppliers, to both better serve their patients and improve their “bottom line.” Yet when it comes to services reimbursed by the government — be it Medicare, Medicaid, or TRICARE — what exactly those terms are and how

Two federal appellate-court decisions handed down in the past few weeks have generated much speculation about whether “medical necessity” determinations underlying Medicare or Medicaid claims can now be considered “objectively false” — despite conflicting medical-expert opinions — and actionable under the False Claims Act (FCA). The most recent opinion was issued on July 9, 2018,

On June 11, 2018, the United States Court of Appeals for the Sixth Circuit sustained a complaint against a home health care agency alleging that the agency had violated the False Claims Act (FCA) by submitting numerous claims to the Medicare program, even though the agency had not timely received the requisite physician certifications of

Earlier this month, the federal District Court for the Northern District of Illinois, in U.S. ex rel. Derrick v. Roche Diagnostics Corp., sustained a whistleblower, or qui tam, complaint under the False Claims Act filed by a discharged employee of a manufacturer of glucose-testing products, and brought against the manufacturer and a Medicare Advantage

In an important break with the majority of case precedents, the United States Court of Appeals for the Fifth Circuit, reversing the District Court below, held that a Medicare provider, facing a $7.6 million recoupment for alleged overpayments, can file suit in federal court and seek an injunction against ongoing recoupments, even though the provider

The U.S. Attorney for the Southern District of Florida recently intervened in a whistleblower lawsuit brought under the federal False Claims Act, alleging fraudulent billing by a pharmacy reimbursed by the federal government. (U.S. ex rel. Medrano v. Diabetic Care Rx, LLC, No. 15-cv-62617, S.D. Fla.)

What makes this case significant is that

On October 19, 2017, the United States District Court for the Northern District of Illinois, in the case of MedPro Health Providers, LLC v. Hargan, dismissed a home care agency’s suit — without deciding the merits of the agency’s challenge to a Medicare contractor’s determination to suspend the agency’s Medicare payments.  Noting that the delay

The New York State Office of Medicaid Inspector General (“OMIG”) on August 31, 2017 issued its first Compliance Alert this year: “Mandatory Compliance Programs’ Risk Assessments: Changes in Medicaid Reimbursement Systems.”  While sounding the alarm for providers, the alert is unfortunately a missed opportunity to offer providers more concrete compliance guidance, in that it does not identify the specific risk areas associated with the new and emerging payment models and particular steps providers should be taking to mitigate those risks.  Instead, OMIG leaves it to the providers, along with their compliance counsel, to sort out the issues themselves.

As OMIG notes, New York State’s Medicaid program, much like Medicare and other state Medicaid program initiatives, is moving away from fee-for-service reimbursement to “new payment methodologies, including capitation, risk-sharing arrangements, and value-based payments, among others.”  OMIG continues: “in a fee-for-service environment, a provider’s compliance program should be focused on whether a covered-medically necessary service was: delivered, correctly coded, billed accurately and timely, and met established quality of care standards.”  In light of the sea change in health care delivery and payment systems, OMIG cautions that, to comply with mandatory compliance-program requirements, providers should “closely review reimbursement methodologies so they can identify where they may need to update risk-assessment activities” – beyond billing and payment processes associated with fee-for-service – to include the “processes involved in the delivery of Medicaid reimbursable services.”
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On June 22, 2017, the United States Court of Appeals for the Fifth Circuit, in Maxmed Healthcare, Inc. v. Price, upheld an administrative determination by a Medicare Administrative Contractor (MAC) based on an audit of a sample of 40 home care claims. From its sample findings, the MAC extrapolated to a universe of 130