Lynne M Halbrooks is a Partner in our Washington DC office.
In United States ex rel. Benjamin Poehling v. UnitedHealth Group, Inc. et al., Case No. CV 16-08697 (C.D. Cal. Feb. 18, 2018), the court dismissed only half of the claims in a qui tam case against UnitedHealth Group, Inc., a Medicare Advantage plan provider. The court applied the U.S. Supreme Court's "materiality" requirement as outlined in Universal Health Servs. Inc. v. United States ex rel. Escobar, 136 S. Ct. 1989 (2016) in dismissing the government's three False Claims Act (FCA) claims related to submission of false annual Risk Adjustment Attestations. The court found these specific allegations "do not suggest they are likely to influence the payment of money." Conversely, the court did find the government pled facts sufficient to show that the defendant knowingly avoided obligations to repay the Centers for Medicare & Medicaid Services (CMS) by failing to delete invalid diagnosis codes from CMS's Risk Adjustment Processing System. The court also declined to read too much into the agency's continued payment despite its general knowledge of the defendant's alleged conduct. As a result, the defendant still faces exposure under a "reverse false claims" theory for allegedly knowingly avoiding its obligation to repay CMS by failing to delete invalid diagnosis codes.
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