"A case now before the U.S. Supreme Court could mean fewer fraud lawsuits filed against healthcare providers. Or it could at least give them more clarity about what constitutes a violation of the law, experts say.

The Supreme Court announced Friday it would hear Universal Health Services v. United States ex rel Escobar, a case that focuses on one theory whistle-blowers and the government use in bringing False Claims Act cases to court. The act makes it illegal to knowingly submit fraudulent bills to the government, such as for services not actually performed.

In a variation of fraud claims, some whistle-blowers allege that providers submitted false claims by failing to follow certain regulations. Providers sometimes are held liable for not following such regulations even if the government never explicitly stated that following a regulation was a condition of payment, and even if the provider never explicitly vouched that it had complied with the regulation.

The Supreme Court will consider whether whistle-blowers and the government should be allowed to bring FCA cases under this theory, known as implied certification.

“It's a huge deal for healthcare providers,” said Larry Freedman, an attorney with Mintz Levin who defends providers in FCA cases. Legal claims based on implied certification are now “the major driver” of healthcare whistle-blower suits, he added.

Lower courts have been divided on the issue, with some saying it's unreasonable to sue organizations under the act for compliance issues arising from the thousands of pages of state and federal rules. Federal and state agencies, not the courts, should deal with such violations, some courts have said.

Allowing an implied certification argument in situations where it hasn't been clearly expressed that a regulation is a condition for payment could turn the False Claims Act into “a punitive sanction for use against minor regulatory or contractual violations,” Universal Health argues in court papers."

Read more at Modern Healthcare

Too many to post individually over the last few days:

Bristol-Myers Squibb To Pay $14 Million To Settle Charges Of Bribery
California Woman Pleads Guilty In Medicare, Medicaid Fraud Scheme
Columbus Regional Agrees To Pay $35M Over Medicaid Fraud Claims
Atlanta Hospice Reaches $3 Million Settlement In Medicare Fraud Case
Government Accountability Office Report Highlights Improper Payments In Medicare, Medicaid



Bristol-Myers Squibb To Pay $14 Million To Settle Charges Of Bribery.

"WASHINGTON (AP) -- Bristol-Myers Squibb will pay $14.6 million to settle charges from U.S. regulators that its joint venture in China gave cash and other benefits to government health care providers to boost drug sales.

The Securities and Exchange Commission announced the settlement of civil charges Monday with the company, one of the largest drugmakers in the world. Bristol-Myers Squibb, based in New York, makes and sells prescription and over-the-counter medicines worldwide."

Read more at AP



California Woman Pleads Guilty In Medicare, Medicaid Fraud Scheme

"LOS ANGELES – A Placentia woman pleaded guilty Monday to a federal charge stemming from the operation of a hospice that submitted millions of dollars in fraudulent bills to Medicare and Medi-Cal.

Sharon Patrow, 44, entered her plea to a health care fraud count before U.S. District Judge S. James Otero, who set a May sentencing date. Patrow's mother, Priscilla Villabroza -- who is serving a 4 1/2-year term at a federal prison in Victorville for running a separate health care fraud scheme -- is also charged in the case.

The mother and daughter, along with four others, were charged in December with 25 health care fraud and money laundering counts, each of which carries a potential multiple-year prison sentence, according to the U.S. Attorney's Office.

The case involves the formerly Covina-based California Hospice Care, which Villabroza purchased in late 2007 while under investigation in the earlier case, prosecutors said.

Officials allege that between March 2009 and June 2013, California Hospice submitted nearly $9 million in fraudulent bills to Medicare and Medi- Cal for purportedly providing end-of-life care to patients who were, in fact, not dying. The public health programs paid nearly $7.5 million on those allegedly bogus bills."

Read more at OC Register



Columbus Regional Agrees To Pay $35M Over Medicaid Fraud Claims

"COLUMBUS — Last week, the hospital business in Georgia’s second-largest city received a double dose of financial misery. The first round of bad news centered on Columbus Regional Health. State Attorney General Sam Olens announced Friday that Columbus Regional and other related entities had agreed to pay Georgia and the United States up to $35 million to resolve allegations of false Medicaid claims.

Then the Columbus Ledger-Enquirer reported Saturday that the other hospital organization in town, St. Francis, has been told by the feds that it must repay $21.4 million and make major changes in the way it does business. The federal audit report came 10 months after St. Francis said it could not account for about $30 million on its financial books."

Read more at Albany Herald



Atlanta Hospice Reaches $3 Million Settlement In Medicare Fraud Case

"A Georgia hospice company has agreed to pay $3 million to resolve allegations it billed taxpayers for patients who were not terminally ill, the latest such settlement as federal officials target what they call a burgeoning number of abusive hospice schemes.


Guardian Hospice set aggressive targets to recruit and enroll patients it knew were not in the last months of their lives so it could collect Medicare payments, the federal government alleged. In agreeing to the settlement, the for-profit company, which serves the Atlanta area, did not admit liability."

Read more at AJC




Government Accountability Office Report Highlights Improper Payments In Medicare, Medicaid

WASHINGTON: Three health and safety net programs for the poor and elderly accounted for most of the federal government’s $124.7 billion in improper payments in fiscal 2014, the Government Accountability Office reported Thursday.

"The figure, which represents improper payments across 124 federal programs, is up roughly 20 percent from $105.8 billion in fiscal 2013, according to a new GAO report.

Most of the $19 billion increase resulted from erroneous payments under the Medicare, Medicaid and Earned Income Tax Credit programs. They account for more than 75 percent of the GAO’s government-wide improper payment estimate.

Improper payments are those made in error or in an incorrect amount and can include duplicate payments, those made without proper documentation or to ineligible recipients, and payments for ineligible goods and services.

They can result from fraud, unintentional clerical errors or a host of other reasons.

Nearly $1 trillion in improper federal payments have been made since 2003, when a federal law began requiring certain agencies to report the amounts."

Read more at McClacthyDC

"The United States says Novartis AG (NOVN.VX) should pay as much as $3.35 billion in damages and civil fines because the Swiss drugmaker used kickbacks to boost sales of two drugs covered by Medicare and Medicaid.

In papers filed Monday night in Manhattan federal court, the government said it deserves that sum under the federal False Claims Act over alleged improper reimbursements for Exjade, used by patients who receive blood transfusions, and Myfortic, for patients with kidney transplants.

The government is seeking up to $1.52 billion in damages, representing triple the sums allegedly reimbursed and tainted by kickbacks between 2004 and 2013."

Read more at Reuters