United States: Seven Takeaways From The ABA National Institute On Health Care Fraud

Last Updated: June 2 2017
Article by Ellyn Sternfield

On May 17, 2017 the American Bar Association convened its 27th National Institute on Health Care Fraud.  I have attended many of the past annual meetings, and always enjoy the presentations and the opportunity to network with colleagues from all sides of the aisle.  And I always come away with a few nuggets to share with those who did not attend.

Here are my seven top takeaways from this year's Institute.

  1. DOJ Enforcement Priorities: The acting Criminal Chief at the U.S. Department of Justice (DOJ), Kenneth Blanco, was a late addition to the agenda.  Blanco asked to speak, in part, to assure attendees that health care fraud will remain a prime focus of DOJ.  Mr. Blanco highlighted two priority areas of focus for DOJ attorneys: (i) opioid-related cases (an area mentioned by all government speakers), and (ii) Medicare Part D billing.  Without referencing Sally Yates or the "Yates Memo," Mr. Blanco also reiterated DOJ's ongoing commitment to focusing on individual responsibility in pursuing health care fraud cases.
  1. Admissions of Conduct: Blanco did not address the question of admissions of conduct as part of civil False Claims Act (FCA) settlements.  But through other speakers it became apparent that there is not a consistent, nation-wide approach as to whether or not respondents can continue to deny liability, or must admit to alleged conduct, in civil FCA settlements.  While at least one district is presently insisting that respondents admit to responsible conduct as part of any civil FCA settlement, many other districts continue to allow respondents to deny liability to facilitate civil FCA settlements.
  1. Materiality and Escobar: The U.S. Supreme Court decision in U.S. v. Escobar continues to reverberate in civil FCA litigation.  Federal prosecutors recognize that the mere assertion that the government "could" have denied the claim based on the underlying conduct will likely not suffice to establish FCA materiality under Escobar.   Defense attorneys believe that materiality must be judged not by what government attorneys say, but by what affected government agencies do in response to the asserted conduct.  Government attorneys, defense attorneys and relators' counsel are all concerned about the spin being put on the recent 4th Circuit Opinion in Triple Canopy, that materiality can be found based on whether or not the government intervened in a qui tam. 
  1. Kickback Violations: Whether or not it is a result of Escobar, it is clear that kickback violations are now the primary issue being addressed through FCA qui tam
  1. FCA Penalties: Most practitioners know that the FCA penalty assessments, as well as civil monetary penalty assessments, and other types of federal penalty provisions, were significantly increased last year as a result of legislative mandate.  However, the legislation also requires the penalty assessments to be subject to an annual inflation adjustment.  For example, civil FCA claims penalties just went up again to a minimum of $10,957 and a maximum of $21,916 per claim.  Yet to be litigated: is the applicable penalty range determined when the conduct occurred or, as one government attorney opined, by the penalty range that exists when the penalty is assessed?  As an editorial aside, would a court really apply an ex post facto penalty assessment in light of the already-lurking 8th Amendment challenges to the penalties?
  1. OIG: The Office of Inspector General for the U.S. Department of Health and Human Service (OIG) has staffed up its legal team, and, combined with improved data access and analytics, is now pursuing more affirmative civil monetary penalty cases than ever before.  And the OIG is exercising discretion under its announced standards on when to exclude individuals responsible for conduct underlying FCA judgments and settlements.  The average time to resolve an OIG self-disclosure is now under ten months. OIG did not report on whether there was a similar decrease in the average time to respond to a request for an Advisory Opinion.
  1. Access to Care Exception: OIG acknowledged that while the final rule codifying the Access to Care exception to the beneficiary inducement prohibition provides no safe harbor for kickback violations (or potential qui tams for the kickback violation), OIG has no present intention to propose a corollary kickback safe harbor for Access to Care.  However, OIG has issued an Advisory Opinion, #17-1, in which it said that if a proposal met the Access to Care exception for beneficiary inducement, OIG would "exercise its discretion" and would not consider sanctioning the conduct as a kickback.  The clear implication was that OIG would consider similar language in future Advisory Opinions.

On this final point, I believe it is important to note the exact language of Opinion #17-1.  In examining a proposed arrangement to provide needy patients with reduced cost lodging and meals during medically necessary hospital treatments, OIG acknowledged the arrangement qualified for the Access to Care exception for beneficiary inducement.  OIG also stated that it would not sanction the conduct under the kickback prohibition, but in doing so it acknowledged that the proposed arrangement does implicate the anti-kickback statute.  The Opinion also states that the Opinion is only binding on the U.S. Department of Health and Human Services, not on DOJ or any relator.  And the Opinion specifies that OIG is not opining on whether the arrangement could be used to allege potential liability under the false claims act, including an allegation based on alleged kickbacks.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

To print this article, all you need is to be registered on Mondaq.com.

Click to Login as an existing user or Register so you can print this article.

Authors
Ellyn Sternfield
 
In association with
Related Topics
 
Related Articles
 
Related Video
Up-coming Events Search
Tools
Print
Font Size:
Translation
Channels
Mondaq on Twitter
 
Register for Access and our Free Biweekly Alert for
This service is completely free. Access 250,000 archived articles from 100+ countries and get a personalised email twice a week covering developments (and yes, our lawyers like to think you’ve read our Disclaimer).
 
Email Address
Company Name
Password
Confirm Password
Position
Mondaq Topics -- Select your Interests
 Accounting
 Anti-trust
 Commercial
 Compliance
 Consumer
 Criminal
 Employment
 Energy
 Environment
 Family
 Finance
 Government
 Healthcare
 Immigration
 Insolvency
 Insurance
 International
 IP
 Law Performance
 Law Practice
 Litigation
 Media & IT
 Privacy
 Real Estate
 Strategy
 Tax
 Technology
 Transport
 Wealth Mgt
Regions
Africa
Asia
Asia Pacific
Australasia
Canada
Caribbean
Europe
European Union
Latin America
Middle East
U.K.
United States
Worldwide Updates
Registration (you must scroll down to set your data preferences)

Mondaq Ltd requires you to register and provide information that personally identifies you, including your content preferences, for three primary purposes (full details of Mondaq’s use of your personal data can be found in our Privacy and Cookies Notice):

  • To allow you to personalize the Mondaq websites you are visiting to show content ("Content") relevant to your interests.
  • To enable features such as password reminder, news alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our content providers ("Contributors") who contribute Content for free for your use.

Mondaq hopes that our registered users will support us in maintaining our free to view business model by consenting to our use of your personal data as described below.

Mondaq has a "free to view" business model. Our services are paid for by Contributors in exchange for Mondaq providing them with access to information about who accesses their content. Once personal data is transferred to our Contributors they become a data controller of this personal data. They use it to measure the response that their articles are receiving, as a form of market research. They may also use it to provide Mondaq users with information about their products and services.

Details of each Contributor to which your personal data will be transferred is clearly stated within the Content that you access. For full details of how this Contributor will use your personal data, you should review the Contributor’s own Privacy Notice.

Please indicate your preference below:

Yes, I am happy to support Mondaq in maintaining its free to view business model by agreeing to allow Mondaq to share my personal data with Contributors whose Content I access
No, I do not want Mondaq to share my personal data with Contributors

Also please let us know whether you are happy to receive communications promoting products and services offered by Mondaq:

Yes, I am happy to received promotional communications from Mondaq
No, please do not send me promotional communications from Mondaq
Terms & Conditions

Mondaq.com (the Website) is owned and managed by Mondaq Ltd (Mondaq). Mondaq grants you a non-exclusive, revocable licence to access the Website and associated services, such as the Mondaq News Alerts (Services), subject to and in consideration of your compliance with the following terms and conditions of use (Terms). Your use of the Website and/or Services constitutes your agreement to the Terms. Mondaq may terminate your use of the Website and Services if you are in breach of these Terms or if Mondaq decides to terminate the licence granted hereunder for any reason whatsoever.

Use of www.mondaq.com

To Use Mondaq.com you must be: eighteen (18) years old or over; legally capable of entering into binding contracts; and not in any way prohibited by the applicable law to enter into these Terms in the jurisdiction which you are currently located.

You may use the Website as an unregistered user, however, you are required to register as a user if you wish to read the full text of the Content or to receive the Services.

You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these Terms or with the prior written consent of Mondaq. You may not use electronic or other means to extract details or information from the Content. Nor shall you extract information about users or Contributors in order to offer them any services or products.

In your use of the Website and/or Services you shall: comply with all applicable laws, regulations, directives and legislations which apply to your Use of the Website and/or Services in whatever country you are physically located including without limitation any and all consumer law, export control laws and regulations; provide to us true, correct and accurate information and promptly inform us in the event that any information that you have provided to us changes or becomes inaccurate; notify Mondaq immediately of any circumstances where you have reason to believe that any Intellectual Property Rights or any other rights of any third party may have been infringed; co-operate with reasonable security or other checks or requests for information made by Mondaq from time to time; and at all times be fully liable for the breach of any of these Terms by a third party using your login details to access the Website and/or Services

however, you shall not: do anything likely to impair, interfere with or damage or cause harm or distress to any persons, or the network; do anything that will infringe any Intellectual Property Rights or other rights of Mondaq or any third party; or use the Website, Services and/or Content otherwise than in accordance with these Terms; use any trade marks or service marks of Mondaq or the Contributors, or do anything which may be seen to take unfair advantage of the reputation and goodwill of Mondaq or the Contributors, or the Website, Services and/or Content.

Mondaq reserves the right, in its sole discretion, to take any action that it deems necessary and appropriate in the event it considers that there is a breach or threatened breach of the Terms.

Mondaq’s Rights and Obligations

Unless otherwise expressly set out to the contrary, nothing in these Terms shall serve to transfer from Mondaq to you, any Intellectual Property Rights owned by and/or licensed to Mondaq and all rights, title and interest in and to such Intellectual Property Rights will remain exclusively with Mondaq and/or its licensors.

Mondaq shall use its reasonable endeavours to make the Website and Services available to you at all times, but we cannot guarantee an uninterrupted and fault free service.

Mondaq reserves the right to make changes to the services and/or the Website or part thereof, from time to time, and we may add, remove, modify and/or vary any elements of features and functionalities of the Website or the services.

Mondaq also reserves the right from time to time to monitor your Use of the Website and/or services.

Disclaimer

The Content is general information only. It is not intended to constitute legal advice or seek to be the complete and comprehensive statement of the law, nor is it intended to address your specific requirements or provide advice on which reliance should be placed. Mondaq and/or its Contributors and other suppliers make no representations about the suitability of the information contained in the Content for any purpose. All Content provided "as is" without warranty of any kind. Mondaq and/or its Contributors and other suppliers hereby exclude and disclaim all representations, warranties or guarantees with regard to the Content, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. To the maximum extent permitted by law, Mondaq expressly excludes all representations, warranties, obligations, and liabilities arising out of or in connection with all Content. In no event shall Mondaq and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use of the Content or performance of Mondaq’s Services.

General

Mondaq may alter or amend these Terms by amending them on the Website. By continuing to Use the Services and/or the Website after such amendment, you will be deemed to have accepted any amendment to these Terms.

These Terms shall be governed by and construed in accordance with the laws of England and Wales and you irrevocably submit to the exclusive jurisdiction of the courts of England and Wales to settle any dispute which may arise out of or in connection with these Terms. If you live outside the United Kingdom, English law shall apply only to the extent that English law shall not deprive you of any legal protection accorded in accordance with the law of the place where you are habitually resident ("Local Law"). In the event English law deprives you of any legal protection which is accorded to you under Local Law, then these terms shall be governed by Local Law and any dispute or claim arising out of or in connection with these Terms shall be subject to the non-exclusive jurisdiction of the courts where you are habitually resident.

You may print and keep a copy of these Terms, which form the entire agreement between you and Mondaq and supersede any other communications or advertising in respect of the Service and/or the Website.

No delay in exercising or non-exercise by you and/or Mondaq of any of its rights under or in connection with these Terms shall operate as a waiver or release of each of your or Mondaq’s right. Rather, any such waiver or release must be specifically granted in writing signed by the party granting it.

If any part of these Terms is held unenforceable, that part shall be enforced to the maximum extent permissible so as to give effect to the intent of the parties, and the Terms shall continue in full force and effect.

Mondaq shall not incur any liability to you on account of any loss or damage resulting from any delay or failure to perform all or any part of these Terms if such delay or failure is caused, in whole or in part, by events, occurrences, or causes beyond the control of Mondaq. Such events, occurrences or causes will include, without limitation, acts of God, strikes, lockouts, server and network failure, riots, acts of war, earthquakes, fire and explosions.

By clicking Register you state you have read and agree to our Terms and Conditions