Case shows wide reach of fraud regs
Case shows wide reach of fraud regs
The allegations of Medicare fraud at the Tulare (CA) Regional Medical Center and its parent, the Tulare District Healthcare System, show how whistle-blower cases can go beyond the classic type of kickbacks, says Anne Sage, JD, director of the legal group with the Los Angeles law firm of Casey & Sayre.
Most False Claims Act (FCA) cases involve allegations of fraudulently overcharging the government, knowingly selling the government defective or improperly tested products, or knowingly failing to deliver contractual services, she notes. In those cases, the whistle-blower or the government must prove that the particular payment request was itself false.
"This was not one of those cases. In recent years, whistle-blowers have filed lawsuits alleging that the defendant fully performed the services described in the claim thereby delivering exactly what the government paid for but did so while violating a regulation that governs the defendant's business," Sage says. "The premise of this case is that the Medicare reimbursement claims were, on their face, accurate, but that at the same time the hospital was properly performing its health services, it was violating laws and regulations governing its business arrangements with physicians."
Kickback allegations may affect claims
The question in the case was whether the hospital's violation of "kickback" rules turns its otherwise truthful and accurate Medicare reimbursement claims into false claims, Sage explains. Some courts have imposed liability under FCA in that situation on the theory that each reimbursement claim somehow by implication certifies that the hospital is compliant.
"Those decisions have expanded the reach of the False Claims Act and its treble damages provision to areas that are more appropriately governed by other laws," she says. "In other words, the Anti-Kickback Act has its own remedies, and enforcement should not be subsumed by the False Claims Act. As one court correctly put it: 'The False Claims Act was not designed for use as a blunt instrument to enforce compliance with all medical regulations but rather only those regulations that are a precondition to payment... .'"
Source
For more information on whistle-blower cases, contact:
Anne Sage, JD, Director, Legal Group, Casey & Sayre, Los Angeles. Telephone: (310) 473-8090. E-mail: [email protected].
The allegations of Medicare fraud at the Tulare (CA) Regional Medical Center and its parent, the Tulare District Healthcare System, show how whistle-blower cases can go beyond the classic type of kickbacks...Subscribe Now for Access
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