Tag:FCA
Escobar’s Materiality Standard Shields Organizations from the Risk in Risk Adjustment Payments
Finance Director for UnitedHealth Group brought qui tam suit against UnitedHealth Group, Inc. alleging that the organization upcoded risk adjustment data resulting in increased payments (more than $1.14 billion) to UnitedHealth Group. The Department of Justice (DOJ) intervened in the case, yet UnitedHealth Group was successful in getting the primary False Claims Act Claims dismissed by arguing that the Centers for Medicare & Medicaid Services (CMS) would not have refused to make the adjustment payments had they known of the errors in the risk adjustment. The Escobar materiality standard helps clarify threshold level of risk to Managed Care Providers in attesting to their risk adjustment payments; the falsities must have had an impact on the respective payment.
DOJ Joins Whistleblower Suit Against UnitedHealth Group
The United States Department of Justice (“DOJ”) recently intervened in a qui tam action against UnitedHealth Group (“United”) and its subsidiary, UnitedHealthcare Medicare & Retirement, the nation’s largest provider of Medicare Advantage (“MA”) Plans. The suit alleges that United engaged in an “up-coding” scheme to receive higher payments than they should have under MA’s risk adjustment program. Assuming these allegations of United’s false claims are true, then United billed and received hundreds of millions of dollars in improper payments from Medicare.
The Baxter Settlement and its Implications for FCA Liability
Kaitlin Lavin Executive Editor Loyola University Chicago School of Law, JD 2017 In January, Baxter Healthcare Corporation (“Baxter”) agreed to pay $18,158 million after the Department of Justice (DOJ) brought suit for violating the Food, Drug, and Cosmetic Act (FCDA) and the False Claims Act (FCA). The Baxter case is unique because it was …
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New Era of Healthcare Fraud Investigations Focuses On Individual Accountability
Fannie Fang Executive Editor Loyola University Chicago School of Law, JD 2017 Traditionally, only healthcare corporations were held responsible for healthcare fraud. During an investigation, these corporations were only required to provide contextual information about the underlying factual situation in a fraud investigation. Additionally, healthcare corporations would typically enter into settlement agreements with the …
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Another Suit against Vanguard Healthcare
Kaitlin Lavin Executive Editor Loyola University Chicago School of Law, JD 2017 In 2011, Vanguard Healthcare, LLC (“Vanguard”) settled a whistleblower suit for Medicare and Medicaid fraud and entered into a Corporate Integrity Agreement (CIA). Now the federal government is suing Vanguard for submitting fraudulent claims for services that were “either non-existent or grossly …
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False Claims Act Penalties Double with DOJ New Interim Rule
Amanda Bogle Executive Editor Loyola University Chicago School of Law, JD 2017 On June 30, 2016, the Department of Justice joined other agencies in passing a new interim final rule, significantly increasing the penalties for the False Claims Act (FCA). Before, FCA penalties ranged from $5,500 up to $11,000 per false claim. The new …
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Implied Certification: What does it mean for your small business?
Brittany Tomkies Executive Editor Loyola University Chicago School of Law, JD 2017 In a monumental decision for false claims cases, the Supreme Court of the United States (SCOTUS) unanimously affirmed the viability of the implied certification theory. The ramifications of this ruling may create additional stressors on small businesses and will likely create additional …
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An Active Summer of Healthcare Fraud Enforcement Actions
Alanna J. Kroeker Executive Editor Loyola University Chicago School of Law, JD 2017 Unprecedented DOJ Healthcare Fraud Takedown: On Wednesday June 22, Attorney General Loretta Lynch and Department of Health and Human Services (HHS) Secretary Sylvia Burwell announced the largest healthcare fraud takedown in history. This action was led by the Medicare Fraud Strike …
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Supreme Court Weighs in on Implied False Certification Theory
Ryan Meade Editor-in-Chief Director of Regulatory Compliance Studies at Loyola University Chicago School of Law The Supreme Court’s decision yesterday in Universal Health Services, Inc. v. U.S. ex rel Escobar (“UHS”) has had some strange initial summaries suggesting this is a gloom and doom opinion for actors who submit claims to the United States. I …
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Adding Federal Grant Compliance to the Audit Plan: the University of Florida Case
Greg Grabinski Executive Editor Loyola University Chicago School of Law, JD 2016 One of the best sources for designing a compliance program’s annual audit plan is to look around to see what is happening at peer institutions. If there is a regulatory settlement in a peer organization’s similar business line, then the subject-matter should …
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