In a recent False Claims Act ("FCA") case, U.S. ex. rel. Schuhardt v. Washington Univ., the Eastern U.S. District Court in Missouri held that a teaching hospital could be liable for fraud when physicians were not present during billed surgeries. Medicare Part B payments are made when physicians involve residents in the care of their patients and bill for services. The court held that until June of 1996, Medicare required a teaching physician to be physically present for both surgical services and pre- and post-operative care in order to receive reimbursement. After 1996, the teaching physician was required to be present during "key" portions of the billable service or perform that portion of the billable service herself. If the teaching physician is not physically present for these key portions, then a reduced global fee should be billed to Part B. The court denied the defendant's motions to dismiss the case, holding that the plaintiffs had stated a valid claim under the FCA and that the plaintiffs had pleaded their case with particularity when the plaintiffs substantiated general allegations within the complaint with specific allegations.
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27 March 2003