tci Medicare Compliance & Reimbursement - 2016 Issue 17

False Claims Act: SCOTUS Draws Boundaries for FCA and Future Liability

Hint: Common law takes into account both acts of commission and omission. Can fraud be implied or does it have to be perceptible? Do your providers have the certification they need to justify their medical decision making and subsequent billing? Can payers withhold payment if they become aware of non-compliance with certification requirements? A recent U.S. Supreme Courtjudgement provides some answers to these questions. Background: The case of Universal Health Services v. U.S. ex rel. Escobarwas based on a young woman receiving mental health and therapeutic services from healthcare providers employed byUniversal Health Services(UHS) — providers who...

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