Federal judge OKs statistical sampling of nursing home claims to support fraud charges

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The government can use a statistical sample of a nursing home company's Medicare claims to help prove overbilling charges, a federal judge recently decided in an unprecedented ruling.

The legal decision involves a high-profile False Claims Act case against Life Care Centers of America, which is facing allegations that it systematically provided unnecessary therapy to maximize reimbursements. The federal government — which intervened in the case in 2012 — proposed sampling 400 claims from 82 Life Care Centers locations and then extrapolating from those numbers to help prove that routine overbilling occurred company-wide.

Life Care Centers countered that the FCA requires the government to furnish evidence of particular instances of false claims.

The government can “specify in detail the specific claims” that it believes are false, but the sheer number of claims makes them impossible to consider individually, Judge Harry S. Mattice Jr. wrote in his Sept. 29 decision. In what might be an ominous note to providers, he emphasized that the growth of government programs makes statistical sampling an increasingly relevant legal tool.

“The purpose of the FCA as well as the development and expansion of government programs as to which it may be employed support the use of statistical sampling in complex FCA actions where a claim-by-claim review is impracticable,” he wrote.

Mattice stated that Life Care Centers can argue in court that not much weight should be given to the “extrapolated evidence.”

Extrapolation already is widely used in determining Medicare overpayment amounts and the amount of damages in False Claims cases. However, this might be the first instance in which it is allowed as a means of proving wrongdoing, Bloomberg BNA reported.*

*Editor's Note: A previous version of this article referred to this news source as the Bureau of National Affairs. It has not gone by this name since 2011.