SCOTUS to review False Claims definition

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Providers could be getting help soon over anxieties about potential False Claims Act charges.

The Supreme Court of the United States has announced it will review what exactly constitutes “false” under the act's provisions. Long-term care operators and rehab specialists will be keenly interested in the outcome.

Recent cases have resulted in charges against, and sometimes-huge settlements with, major long-term care and rehabilitation providers. Authorities have taken on some of the largest long-term care players in the U.S. and won, alleging illegal billing for unnecessary, insufficient or non-existent services.

The nation's highest court opened the door by agreeing on Dec. 4 to review a U.S. District Court's decision on a Massachusetts case. The petition raises the question of whether the theory of implied certification can be actionable under the FCA. 

At the core is the question: If the provider didn't comply with a regulation that isn't specifically a condition of reimbursement, can its claim be “legally false”?

The case in question involves a Massachusetts clinic whose Medicaid reimbursement claims were deemed false because its services didn't comply with certain regulations, despite the clinic saying it was compliant each time it filed a claim, according to court documents.

The issue is one that's critical to the healthcare industry as “more whistleblower suits assert regulatory violations or breaches of contract as a basis of fraud,” attorney Kathleen McDermott of Washington, D.C. firm Morgan Lewis & Bockius LLP told Bloomberg BNA

As more of those types of suits are filed, it becomes “less obvious the FCA is applicable,” and harder to identify fraudulent conduct that impacts payment, McDermott said.