The FCA Insider

The FCA Insider

Insights and updates on False Claims Act Litigation

DOJ

DOJ Puts Collection of Civil Penalties on Hold in Response to COVID-19

In a pair of recent memoranda from the Executive Office for United States Attorneys (“EOUSA”) issued on March 31, 2020, and April 13, 2020, the United States Department of Justice (“DOJ”) has effectively halted enforcement actions and the collection of civil penalties.  Included in this temporary suspension is the collection of civil penalties incurred in suits under the False Claims Act (“FCA”).  The FCA is the federal government’s primary tool for recourse against false or fraudulent claims made against government programs.

In the FCA context, this suspension has implications for key government programs in light of the current coronavirus outbreak, including Medicare and Medicaid.  Pursuant to this new guidance, U.S. Attorney’s Offices will temporarily suspend enforcement activity on civil debt levied against health care providers who billed the government insurance programs for goods and services that were not rendered, were substandard, and/or medically unnecessary.  The temporary suspension will also affect enforcement activity on civil debt levied against other government contractors.

This moratorium on the collection of civil debt is effective until at least May 31, 2020, and may potentially be extended either by legislation or administrative action.  The temporary suspension applies broadly to collection activity on civil debts, including debts in active repayment.  The memoranda direct the U.S. Attorney’s Offices not to pursue new enforcement actions, and payments scheduled under active payment plans will not be considered in default if left unpaid.  However, interest may accrue depending on the type of civil debt, and affected parties may continue to make voluntary payments on interest or their full penalties.  The April 13, 2020, memorandum from the EOUSA clarifies that the collection of debts pursuant to voluntary settlement agreements may continue, since they are appropriately considered “voluntary payments.”

Although affirmative civil debt collection and enforcement actions are temporarily suspended, U.S. Attorneys may continue to investigate claims, file complaints, litigate cases to judgment, settle any affirmative civil enforcement matter, and pursue preparatory collection actions and other measures to protect the government’s interests.  This temporary suspension does not apply to ongoing litigation, appeals, or cases not subject to a final, non-appealable judgment, and the government’s remedies for breach of any settlement agreement remain intact at this time.

In addition, this temporary suspension does not extend to the collection of criminal penalties, including fines and restitution that are the result of a criminal conviction or plea and entered pursuant to a court order or judgment under a criminal statute.

Entities and individuals currently making payments to the federal government who wish to take advantage of the temporary suspension should ensure they fall within the parameters of the memoranda.  Before delaying payments, entities and individuals should seek legal guidance from their existing counsel or retain counsel to discuss their potential options, including possible outreach to the relevant authorities.

Please contact the authors for additional guidance on how these issuances and other COVID-19 considerations will affect federal enforcement actions and the related rules. McGuireWoods has published additional thought leadership related to how companies across various industries can address crucial coronavirus-related business and legal issues.

OIG, Regulatory

OIG Requests Inquiries on Enforcement Related to COVID-19 Arrangements

On April 3, 2020, OIG issued a process for inquiries to be submitted to OIG about the application of administrative enforcement authorities against certain arrangements directly connected to the 2019 novel coronavirus (COVID-19). OIG particularly asked for inquiries related to the Federal anti-kickback statute and civil monetary penalties prohibition on beneficiary inducements, where enforcement discretion may allow the healthcare system to function during this pandemic. OIG responses, including its first two responses described below, will be publicly available through a frequently asked questions (FAQ) posting on the OIG COVID-19 portal.

This initiative continues OIG’s efforts to simplify provider compliance during the COVID-19 pandemic. Last month, OIG issued a letter outlining its general perspective on enforcement during the COVID-19 crisis and this new process is intended to clarify OIG’s position. Questions can be submitted to OIGComplianceSuggestions@oig.hhs.gov with sufficient facts to allow for an understanding of the key parties and terms of the arrangement. OIG will not review questions related to the Federal Stark Law (providers can ask the Centers for Medicare & Medicaid Services for a waiver here) or the False Claims Act, and any feedback provided is limited to arrangements in existence during the COVID-19 public health emergency.

Currently OIG’s FAQs consists of two responses to public inquiries:

  1. Providers assisting long-term care providers. The first question was whether health care providers and practitioners can provide services for free or at a reduced rate to long-term care providers that are facing staffing shortages due to COVID-19. OIG opined on two fact-specific scenarios that fit within the broader question. The first scenario involves a hospice vendor that is already providing services to patients at a skilled nursing facility providing additional free basic care services, within its scope of practice, to clients at the facility that are not the hospice’s patients in order to help mitigate staffing shortages. The second scenario involves a skilled nursing facility fulfilling patient care needs that are unmet due to staffing shortages, by using community dentists or podiatrists who are not working at full capacity and are willing to offer services for free or at a reduced rate. Typically providing services to such facilities could be seen as an inducement to refer care that is more specialized. In both cases, OIG opined that the fraud and abuse risk is low during the COVID-19 outbreak so long as the following four conditions are met. First, the services being offered are necessary to meet patient care needs that are a result of staffing shortages directly connected to the COVID-19 outbreak. Second, the services being offered are being provided for free or at a reduced cost only when necessary because of the COVID-19 outbreak. Third, the services being offered are limited to the period during the COVID-19 public health emergency declaration. Fourth, the services being offered are not contingent on referrals for any items or services that may be reimbursable in whole or in part by a Federal health care program, whether during or after the COVID-19 public health emergency declaration.
  2. Hospitals assisting independent physicians on medical staff. The second question was whether a hospital may provide free access to an existing web-based telehealth platform to independent physicians on the hospital’s medical staff. In this scenario, the hospital would receive no payment from either the independent physicians receiving access or any payor for services provided through the telehealth platform by the independent physicians. Likewise, the physicians would not receive any remuneration from the hospital beyond access to the telehealth platform, would be responsible for maintaining any required records for patients seen through the platform, and must independently bill and receive reimbursement for any professional services provided. OIG opined that such an arrangement would pose low risk of fraud and abuse so long as the following four conditions are met. First, the platform must only be provided for free in order to facilitate medically necessary services. Second, the platform must only be provided only when necessary because of the COVID-19 outbreak, and only during the period of the public health emergency. Third, access to the platform must not be contingent on the physicians’ past or anticipated volume or value of referrals to the hospital for items or services that may be reimbursable by a Federal health care program. Fourth, access must be offered to all physicians on the medical staff on an equal basis, even if not all accept the offer.

McGuireWoods will continue to monitor OIG’s release of further FAQs as additional providers utilize this inquiry mechanism. Providers may welcome the flexibility provided by OIG exercising enforcement discretion during the COVID-19 pandemic assuming that OIG’s FAQ responses continue to provide additional flexibility to providers during COVID-19. OIG will likely require such relationships to end at the end of the COVID-19 public health emergency declaration, and therefore, providers seeking to utilize these statements in care to their communities should plan to terminate the relationship at the end of the pandemic.

McGuireWoods has published additional thought leadership related to how companies across various industries can address crucial coronavirus-related business and legal issues, and the firm’s COVID-19 Response Team stands ready to help clients navigate urgent and evolving legal and business issues arising from the novel coronavirus pandemic.

OIG, Regulatory

OIG Follows the Stark Law COVID-19 Waivers for Anti-Kickback Statute

On April 3, 2020, the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) issued a policy statement announcing that the OIG will exercise its enforcement discretion not to impose administrative sanctions under the federal Anti-Kickback Statute (AKS) for remuneration related to the 2019 novel coronavirus (COVID-19). OIG’s announcement follows the recent blanket waivers issued by the HHS with the Centers for Medicare & Medicaid Services (CMS) to protect certain specified financial relationships and referrals otherwise sanctioned by the Physician Self-Referral Law (Stark Law), as long as they pertain to at least one COVID-19 purpose. The blanket waivers were discussed in an April 3, 2020, client alert.

The OIG will exempt additional arrangements that do not satisfy the safe harbor requirements so long as they satisfy one of the permissible forms of remuneration allowed under the Stark Law blanket waivers.

The AKS is an intent-based statute broadly prohibiting the offer or exchange of anything of value to induce or reward the referral of federal healthcare program business. Because of the AKS’ breadth and because the statute subjects violators to criminal sanctions, the OIG previously issued a series of voluntary safe harbors to protect relationships that do not pose a high risk of fraud or abuse. The April 3 policy statement takes this one step further, explaining that beyond these safe harbors, the OIG will exempt additional arrangements that do not satisfy the safe harbor requirements so long as they satisfy one of the permissible forms of remuneration allowed under the Stark Law blanket waivers (specifically, Section II.B(1)-(11) of the blanket waivers). To be clear, the policy statement does not cover all of CMS’ Stark Law enumerated blanket waivers related to referral relationships (specifically Section II.B(12)-(18) of the blanket waivers)

OIG’s decision not to enforce certain administrative sanctions against arrangements that may otherwise implicate the AKS is another way HHS is giving providers more flexibility during the COVID-19 pandemic. In a recent letter, OIG stated specifically its desire to minimize burdens on providers during the crisis. Here, too, OIG is providing enforcement discretion related to the AKS to ensure flexibility for providers that meet the Stark Law blanket waivers. OIG also made it clear that it was extending its non-enforcement discretion to referrals for all federal healthcare program beneficiaries stemming from the arrangement.

In releasing the policy statement, OIG stated that all conditions and definitions that apply to the blanket waivers would need to be satisfied for a provider to receive this enforcement discretion. The conditions include: (i) the providers are acting in good faith to provide care in response to the COVID-19 pandemic, (ii) the government does not determine that the financial relationship creates fraud and abuse concerns, and (iii) providers seeking protection under this policy statement maintain sufficient documentation. For more information on these conditions, view the McGuireWoods April 3, 2020, client alert.

On the other hand, recognizing the differences between the AKS and the strict liability Stark Law, OIG diverted from the blanket waivers in some material ways:

  1. The Policy Statement Protects Only Remuneration. Unlike the blanket waivers, which provide protections for certain enumerated remuneration as well as certain referral relationships, the policy statement protects only the permissible forms of remuneration specified in the blanket waivers. Therefore, the policy statement would not protect the following, even though they are protected under the blanket waivers with respect to the Stark Law:
    1. Referrals by owners of physician-owned hospitals temporarily expanding their capacity
    2. Referrals by owners of ASCs that temporarily convert to hospitals
    3. Referrals by owners in home health agencies to their HHA
    4. Referrals for in-office ancillary services provided at additional locations, although most physician group intra-practice referrals will still be protected through either the existing AKS group practice investment safe harbor or the employee safe harbor
    5. Referrals of patients located in rural areas to immediate family members
    6. Waiving in-writing requirements of the Stark Law exceptions

    It is important to reiterate that, unlike the strict liability Stark Law, absence of the applicability here of specific blanket waivers does not mean the relationship violates the AKS or that the OIG would take enforcement action. First, another AKS safe harbor may apply. Second, the relationship may not have the intent to induce or reward referrals, which is required to demonstrate a violation.

  2. No Retroactive Effective Date. Where the blanket waivers retroactively apply to arrangements entered into as of March 1, 2020, the policy statement applies only to conduct occurring on or after April 3, 2020. Though OIG does not explain its reasoning for not aligning entirely with the blanket waivers here, pursuant to the statements above about the applicability of the AKS, parties would still be able to argue for protection from AKS sanctions absent an improper motive to induce or reward referrals.
  3. No Protection for Pharmaceutical or Device Manufacturers. OIG states that the policy statement has “no bearing” on arrangements that may implicate the AKS and are not covered by the blanket waivers. As a result, direct financial relationships with pharmaceutical companies or device manufacturers are not protected by the policy statement since they were not included in the blanket waivers, and should be reviewed under the existing AKS framework. Furthermore, because the blanket waivers cover only provider relationships involving physicians, a provider arrangement involving non-physician providers (e.g., nurse practitioners or physician assistants) might not receive the OIG enforcement discretion discussed herein. While this appears to be the official position of OIG based on the policy statement, the blanket waivers would likely still be influential to determining if such non-physician provider relationships had an improper intent, and may be structured with physician groups to cover such relationships as well.

Though OIG does not adopt the blanket waivers verbatim, its policy statement follows CMS to allow providers to pursue certain financial relationships that would allow treatment in the face of the COVID-19 pandemic that may otherwise implicate the AKS. Further, since protections under the policy statement expire at the end of the public health emergency, providers will need to perform a compliance review of their various relationships to ensure each relationship falls within an AKS safe harbor, much as they would need to do regarding the blanket waivers.

Please contact the authors for additional information on the policy statement, the applicability of the Stark Law blanket waivers to the AKS and their availability to various financial relationships. McGuireWoods has published additional thought leadership on how companies across various industries can address crucial coronavirus-related business and legal issues. The firm’s COVID-19 response team stands ready to help clients navigate urgent and evolving legal and business issues arising from the COVID-19 pandemic.

CMS Guidance, Regulatory, Stark Law

Stark Law Waivers Issued During COVID-19 Pandemic

On March 30, 2020, Department of Health and Human Services Secretary Alex Azar issued blanket waivers to permit certain financial relationships and referrals that would otherwise be sanctioned by the Physician Self-Referral Law (Stark Law). The blanket waivers protect those financial relationships and referrals (and the claims submitted as a result thereof) specifically enumerated by the Centers for Medicare & Medicaid (CMS) as pertaining to at least one outlined 2019 novel coronavirus (COVID-19) purpose. These blanket waivers were given a retroactive effective date of March 1, 2020, and thus protect those referrals and financial relationships since that date.

The Stark Law is a strict liability statute that prohibits a physician from making referrals of Medicare and Medicaid designated health services (DHS) to an entity with which the physician (or the physician’s immediate family) has a financial relationship, absent an exception. Typically, if a financial relationship exists between a physician and a DHS entity, the arrangement needs to meet a technical Stark Law exception in order to bill for the referred DHS services. These blanket waivers temporarily permit payments and referrals between physicians and DHS entities if the relationship falls into one of CMS’ stated categories during the COVID-19 pandemic, even if such an arrangement would not meet a Stark Law exception.

These blanket waivers are another way CMS is giving providers more freedom and flexibility as the COVID-19 pandemic continues.

These blanket waivers are another way CMS is giving providers more freedom and flexibility as the COVID-19 pandemic continues. Similar to other Section 1135 waivers issued in response to the COVID-19 public health emergency, these blanket waivers will terminate at the end of the public health emergency. Note that the blanket waivers apply only if: (i) the providers are acting in good faith to provide care in response to the COVID-19 pandemic; (ii) the financial relationship or referral is protected by one of CMS’ 18 permitted relationships (discussed below); and (iii) the government does not determine that the financial relationship creates fraud and abuse concerns.

COVID-19-Related Purposes

CMS’ blanket waivers are limited to remuneration and referrals that are “solely related to COVID-19 Purposes.” However, the blanket waivers define “COVID-19 Purposes” broadly to include the following:

  • “Diagnosis or medically necessary treatment of COVID-19 for any patient or individual, whether or not the patient or individual is diagnosed with a confirmed case of COVID-19;
  • Securing the services of physicians and other health care practitioners and professionals to furnish medically necessary patient care services, including services not related to the diagnosis and treatment of COVID-19, in response to the COVID-19 outbreak in the United States;
  • Ensuring the ability of health care providers to address patient and community needs due to the COVID-19 outbreak in the United States;
  • Expanding the capacity of health care providers to address patient and community needs due to the COVID-19 outbreak in the United States;
  • Shifting the diagnosis and care of patients to appropriate alternative settings due to the COVID-19 outbreak in the United States; or
  • Addressing medical practice or business interruption due to the COVID-19 outbreak in the United States in order to maintain the availability of medical care and related services for patients and the community.”

Though the utilization of a waiver does not require notice or pre-approval from CMS, any provider or physician utilizing a blanket waiver should maintain sufficient documentation supporting reliance on the applicable waiver. Such documents must be made available to the Secretary of HHS upon request. Such documentation should include which of the COVID-19 purposes, outlined above, the relationship was necessary to address. Parties should also articulate which of the below-outlined waivers the parties relied upon in setting up the arrangement. The less any particular arrangement is tied to the COVID-19 pandemic, the greater risk that it could be challenged regarding these blanket waivers.

CMS’ Permitted Financial Relationships

The blanket waivers do not apply to all relationships or waive the Stark Law completely.

The blanket waivers do not apply to all relationships or waive the Stark Law completely. Instead, the waivers apply only to one of 18 enumerated relationships. These 18 enumerated relationships can be described in two broad categories: (1) permissible forms of remuneration and (2) permissible referral relationships. This list summarizes but does not repeat the full listing of 18 enumerated relationships, which are set forth in full in the blanket waivers.

1. Permissible Forms of Remuneration. CMS determined that, solely for the duration of the COVID-19 pandemic, the following categories of remuneration directly between a physician (which in all cases includes a physician’s immediate family member) or a physician’s practice, and an entity that furnishes DHS, are exempted from Stark Law penalties. Importantly, these waivers do not address indirect financial relationships.

  1. Compensation for Personally Performed Services – Remuneration paid by an entity to a physician that is above or below the fair market value (FMV) for the physician’s personally performed services to the entity is permitted by the waivers. For example, if an entity elects to provide an increase in FMV compensation to an already contracted physician to encourage the physician to treat COVID-19 patients during a provider shortage (i.e., overtime or hazard pay), this waiver would protect such compensation.
  2. Office Space and Equipment Rent Payments – Remuneration paid either by an entity to a physician or by a physician to an entity that is below FMV for rental of office space or equipment is permitted by the waivers. These rental payment waivers permit hospital landlords to reduce rental rates for physicians struggling with cash flow as a result of the COVID-19 pandemic to enable physicians to maintain their office space while continuing to provide treatment within the community. These waivers would also permit a hospital to provide physician practices (or practices could provide to a hospital) equipment or space in a tent at no charge to accommodate patient surge due to COVID-19. Notably, these waivers do not protect rental payments that exceed fair market value.
  3. Payments for the Purchase of Items or Services – Remuneration paid by an entity to a physician, or by a physician to an entity, that is below FMV for the purchased items or services, including the use of the entity’s premises, is permitted by the purchase waivers. These waivers are intended to permit parties to quickly source needed items or services without overpaying for the service during the COVID-19 pandemic. CMS gave an example of a DHS entity (i.e., an imaging facility) selling personal protective equipment (PPE) to a physician.
  4. Provision of Additional Incidental Benefits to Medical Staff – Remuneration from a hospital to a physician in the form of medical staff incidental benefits that exceed the $36-per-item limit set forth in 42 CFR § 411.357(m)(5) is protected by the medical staff benefit waiver. This waiver allows a hospital to offer a variety of benefits to its medical staff members, including childcare services or a change of clothes to a physician while the staff member is on the hospital campus, which otherwise would surpass the typical annual limits established in the regulations.
  5. Provision of Nonmonetary Compensation – Remuneration from an entity to a physician in the form of nonmonetary compensation that exceeds the $423 annual limit set forth in 42 CFR § 411.357(k)(1) is protected by the nonmonetary compensation waiver. Similar to the medical staff benefit waiver, this could allow a DHS entity to provide additional services that would otherwise surpass the limits established by the regulations, even for those individuals not on a hospital’s medical staff, including allowing hospitals to provide free technology/software to a physician practice to facilitate telehealth, free CME on COVID-19 training, and free transportation, childcare, hotel rooms and meals. CMS has not indicated how this nonmonetary compensation waiver will impact the application of the annual aggregate limits on nonmonetary compensation provided the rest of the year outside the public health emergency window. CMS may provide further guidance on this point in the future to determine if the full $423 limit will be available the rest of the year; however, if an entity needs to continue offering benefits after the public health emergency, an individual waiver request could be made as discussed further below.
  6. Provision of Low-Interest or Interest-Free Loans – Remuneration between an entity to a physician in the form of a loan by/to either party, with an interest rate below FMV or on terms that are unavailable from a third-party independent lender, is permitted by the loan waiver. Effectively, CMS is providing enhanced ability for providers to make loans to one another to assist with liquidity challenges during the COVID-19 pandemic. For example, a hospital can loan money to an anesthesia group that is providing exclusive anesthesia services at the hospital to help the group offset lost income resulting from the cancellation of elective surgeries due to COVID-19.

2. Permissible Referral Relationships. CMS determined that, solely for the duration of the COVID-19 pandemic, the following categories of referrals between a physician and an entity that furnishes DHS are exempted from the Stark Law requirements.

  1. Referrals by Owners of Physician-Owned Hospitals – Referrals by a physician owner of a hospital that temporarily expands its facility capacity above the number of operating rooms, procedure rooms and beds for which the hospital was licensed on March 23, 2010 (or, in the case of a hospital that did not have a provider agreement in effect as of March 23, 2010, but did have a provider agreement in effect on December 31, 2010, the effective date of such provider agreement), without prior application and approval of the expansion of facility capacity will not be deemed prohibited by Stark (discussed in a April 1, 2020, client alert).
  2. Referrals by Owners of ASCs That Temporarily Convert to Hospitals – Referrals by a physician owner to an ambulatory surgery center (ASC) that such physician owns, following the ASC’s conversion to and enrollment as a Medicare-participating hospital, during the period of the public health emergency will be not a Stark Law prohibited referral, even if the ASC is unable to satisfy certain hospital ownership and investment restrictions, which will be discussed in a forthcoming alert.
  3. Referrals by Owners in Home Health Agencies – Referrals by a physician to a home health agency owned by the physician (or the physician’s immediate family member) and which does not otherwise satisfy the rural provider requirements will not be deemed prohibited by the Stark Law. CMS specifically noted that it was permitting a physician to refer a Medicare beneficiary to a home health agency owned by the physician because there may not be other home health agencies with capacity to provide medically necessary services due to the COVID-19 pandemic.
  4. Referrals for In-Office Ancillary Services at Additional Locations – Intra-group practice referrals for medically necessary DHS will continue to be protected under the in-office ancillary services exception (IOASE), but the blanket waivers extend the exception to be available at additional locations. Specifically, CMS will allow the IOASE to apply during the public health emergency in the following locations: (1) a practice location where DHS is furnished that does not qualify for all requirements set forth in the “same building” or “centralized building” definitions contained in the IOASE requirements; or (2) in the patient’s private home, an assisted living facility or an independent living facility in circumstances where the referring physician’s principal medical practice does not consist of treating patients in their private homes. If a patient is too sick to leave his or her place of residence, physicians would be able to furnish medically necessary DHS (e.g., radiology services or other imaging services) outside the group practice’s office location and not violate the in-office ancillary services requirements. Further, the relaxation of the “same building” or “centralized building” requirements could permit physicians to provide medically necessary DHS to patients in mobile vans, other pop-up locations, or even some shared office spaces in response to the COVID-19 pandemic.
  5. Rural Referrals to Immediate Family Members – Referrals by a physician to an entity with which the physician’s immediate family member has a financial relationship, where the referred patient resides in a rural area, will not be deemed a Stark Law prohibited referral. The Stark Law protects certain rural referrals, but to utilize this exception, certain technical rules must be satisfied. The blanket waivers instead focus on whether the patient is from a rural area, and if the patient is, the physician can refer that patient to an immediate family member without meeting the other technical rules of the referral requirements.
  6. Waiving In-Writing Requirements – CMS is further relaxing any in-writing requirements under Stark Law exceptions. Stark Law compensation arrangement exceptions often require the arrangement to be in writing. While CMS previously granted flexibility here, allowing a collection of writings instead of a single contract to satisfy this requirement, the blanket waivers will simply remove the in-writing requirements under an applicable Stark Law exception provided all other requirements of the exception are satisfied. For example, if a hospital delivers PPE to a physician practice during the COVID-19 pandemic, a signed contract will not be necessary as long as the other elements of an applicable exception are met.

Though certain examples applying the blanket waivers are included above, the examples provided are only illustrative. CMS provided additional examples on pages 6-7 of its guidance document.

Fraud and Abuse

The blanket waivers require that the arrangement not pose risk of program fraud or abuse.

The blanket waivers require that the arrangement not pose risk of program fraud or abuse. CMS likely intended this language to protect the Medicare program from abusive relationships. Therefore, DHS entities and providers should not view these blanket waivers as a pathway to provide improper remuneration by the entity to the physician.

Unfortunately, the blanket waivers document does not provide further guidance for physicians and DHS entities about how CMS may use this language to limit the applicability of the blanket waivers. Without further context, this language adds ambiguity on whether relationships will qualify for protection. Potentially, this requirement could mean these blanket waivers will not be available if the relationship violates the federal Anti-Kickback Statute (AKS). However, CMS recently proposed to remove certain regulatory ties between the strict liability Stark Law and the intent-based AKS.

Consistent with the discussion in the COVID-19-related purposes section above, providers should document the reasons why the arrangement was necessary and in good faith for providing services in response to COVID-19. Providers should also recognize that more aggressive relationships could be challenged, particularly if there are not strong ties to the COVID-19-related purpose, or if the arrangement appears to incentivize DHS referrals.

Post COVID-19 Considerations

While these blanket waivers will offer certain providers relief and flexibility during the COVID-19 pandemic, they only last for the duration of the public health emergency. Thereafter, providers will need to perform a compliance review with their various arrangements under the Stark Law. This review should include at least the following:

  • Ensuring appropriate documentation for any arrangement entered into during the public health emergency to ensure the documentation (i) details the appropriate COVID-19 purpose and (ii) specifies which of the approved blanket waivers the provider utilized
  • Returning any items that an entity may have provided to a physician (or that a physician provided to an entity) during this time due to one of the waivers, including but not limited to, telehealth equipment, EHR software that does not otherwise meet the applicable exception, mobile vans and other medical equipment that may have been necessary to combat the COVID-19 pandemic
  • Terminating any financial relationships allowed under the blanket waivers at the end of the public health emergency, or, if the parties wish to maintain the financial relationship, ensuring such now satisfies an applicable Stark Law exception (e.g., compensation and rental rates that are FMV under their applicable exceptions)

* * * * *

CMS offered the above blanket waivers under its authority under Section 1135 of the Social Security Act in order to reduce burdens on physicians and DHS providers during the COVID-19 pandemic. While not entirely waiving the Stark Law, CMS’ waivers will provide flexibility in navigating the COVID-19 pandemic to allow physicians and providers to focus attention on patient care. CMS encourages providers to email 1877CallCenter@cms.hhs.gov with any questions about the blanket waivers. Providers should include the words “Request for 1877(g) Waiver” in the subject line and include the following minimum information:

  • Name and address of the requesting entity
  • Name, phone number and email address of the person designated to represent the entity
  • CMS Certification Number (CCN) or Taxpayer Identification Number (TIN) of the requesting entity
  • Nature of the request

In the event a specific financial relationship does not fall within the scope of CMS’ enumerated categories, an individual waiver could be requested by email to the appropriate regional office.

Please contact the authors for additional information on the Stark Law blanket waivers and their availability to providers. McGuireWoods has published additional thought leadership on how companies across various industries can address crucial coronavirus-related business and legal issues. The firm’s COVID-19 response team stands ready to help clients navigate urgent and evolving legal and business issues arising from the COVID-19 pandemic.

OIG, Regulatory

OIG Seeks to Minimize Provider Burdens amid COVID-19 Crisis

On March 30, 2020, Christi A. Grimm, Principal Deputy Inspector General of the Department of Health and Human Services (HHS) Office of Inspector General (OIG), issued a letter to the OIG’s website outlining the OIG’s perspective on enforcement during the 2019-novel coronavirus (COVID-19) crisis. Consistent with our recent experiences, OIG stated its desire to minimize burdens on providers during the COVID-19 pandemic.

OIG explains that its focus is on coordinating with HHS, CMS, and law enforcement to support the health care system’s response to the pandemic. While some increased enforcement arises in response to bad actors abusing any crisis—as we previously wrote about with respect to defrauding with fake testing kits and to stealing patient information–OIG is demonstrating increased flexibility in recognition of the current burdens on providers.

To this end, OIG encourages healthcare organizations that need extensions of any OIG deadlines, such as data productions for OIG review or reports submitted pursuant to Corporate Integrity Agreements, to discuss potential extensions with their OIG contact. OIG explains that it intends to work with organizations to reach reasonable solutions. Our recent interactions with OIG are consistent with this statement.

Further, OIG explains that, during the crisis, it will carefully consider context and intent surrounding any actions that would generally be subject to administrative enforcement in determining whether to proceed with enforcement actions. Such statements may give providers comfort to pursue relationships that will allow for urgent and necessary care and treatment to be provided for their communities during the COVID-19 pandemic, even where the relationship does not fall squarely within an Anti-Kickback Statute safe harbor but where there is no intention to induce or influence referrals. Such statements are also consistent with CMS’ blanket waivers under the Stark Law relating to specific relationships addressing COVID-19 purposes, as will be discussed in a forthcoming McGuireWoods’ alert .  To be clear, through Grimm’s letter, OIG is not by any means amending or removing the existing fraud and abuse regulations and corresponding enforcement framework.  Thus, entities must still carefully evaluate their relationships and conduct from a compliance perspective albeit in light of the challenges posed by the COVID-19 pandemic.

Finally, OIG requests that submissions to the OIG be done electronically where possible rather than by mail. The OIG has created a COVID-19 Portal for such submissions. This portal is up to date with information about OIG operations, contact information, and COVID-related work, as well as enforcement questions. Like much of the country, OIG employees are working remotely.

The situation is rapidly evolving and we will continue to monitor any additional federal enforcement actions and information related to COVID-19. The National Center for Disaster Fraud has provided a hotline (866-720-5721) and email (disaster@leo.gov) to report suspected fraud.

McGuireWoods has published additional thought leadership related to how companies across various industries can address crucial coronavirus-related business and legal issues, and the firm’s COVID-19 Response Team stands ready to help clients navigate urgent and evolving legal and business issues arising from the novel coronavirus pandemic.

DOJ, Regulatory

Federal Authorities Crack Down on Fraudulent COVID-19 Schemes

As the public faces the crisis related to the 2019 novel coronavirus (COVID-19), federal authorities announced initial actions against individuals and companies promoting fraudulent schemes and products to the public. Federal agencies suggest concerns that individuals and companies are targeting vulnerable consumers and seeking to profit from the confusion and widespread fear during the pandemic.

The U.S. Department of Justice (DOJ) announced its first enforcement action filed in federal court against operators of a fraudulent website allegedly engaging in a wire fraud scheme seeking to profit from COVID-19.  The Government alleges that the website offered consumers access to “World Health Organization (WHO) vaccine kits” in exchange for a shipping charge and credit card information.  The DOJ obtained a temporary restraining order requiring that the registrar of the website immediately take action to block public access to it. There are currently no approved vaccines or drugs for COVID-19.

Furthermore, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently alerted the public about fraud schemes wherein scammers are offering COVID-19 tests to Medicare beneficiaries in exchange for personal details, including Medicare information.  The OIG reports that scammers are targeting Medicare beneficiaries using multiple platforms, including social media, telemarketing calls, and even door-to-door visits.  Scammers target this information for use in identity theft schemes and, here, could charge Medicare and Medicaid beneficiaries for unapproved tests or other services.

The Federal Bureau of Investigation (FBI) similarly warned the public, “Scammers are leveraging the COVID-19 pandemic to steal your money, your personal information, or both.” Specifically, the FBI warned that they are seeing fake emails claiming .to be from the Centers for Disease Control and Prevention, phishing emails purporting to accept charitable donations and sales offers of counterfeit treatments or equipment. The FBI specifically wants individuals to be cautious of products claiming to prevent, treat or diagnose COVID-19, as such products are likely fake, counterfeit or unapproved devices.

Finally, similar to the FBI’s concerns, the U.S. Food and Drug Administration (FDA) has warned the public against fraudulent “at-home” COVID-19 testing kits. No such at-home tests have been approved as safe or effective by the FDA, and, accordingly, the FDA and the Federal Trade Commission (FTC) have jointly issued seven warning letters against companies marketing such fraudulent at-home tests. The warning letters are merely a first step, as the FDA notes that it is prepared to take additional actions against any companies selling fraudulent testing kits.

Federal agencies have suggested healthcare providers serve as gatekeepers for consumers, assessing an individual’s condition and approve any requests for COVID-19 testing. Healthcare providers should be aware of this guidance and anticipate serving in this gatekeeping role for patients who may instead be considering unapproved at-home tests if they have not been able to obtain a test in another manner.

*****

The situation is rapidly evolving and we will continue to monitor any additional federal enforcement actions related to COVID-19. The National Center for Disaster Fraud has provided a hotline (866-720-5721) and email (disaster@leo.gov) to report suspected fraud.

McGuireWoods has published additional thought leadership related to how companies across various industries can address crucial coronavirus-related business and legal issues, and the firm’s COVID-19 Response Team stands ready to help clients navigate urgent and evolving legal and business issues arising from the novel coronavirus pandemic.

DOJ

New DOJ Task Force to Target Substandard Nursing Home Care

In a March 3, 2020, speech by Attorney General Bill Barr, the Department of Justice (DOJ) announced a new nursing home enforcement initiative targeting “grossly-substandard” care of Medicare and Medicaid beneficiaries in nursing homes nationwide. The DOJ, in partnership with the U.S. Department of Health and Human Services, will also seek to enhance enforcement of civil and criminal efforts to more aggressively pursue owners and operators of nursing homes that mistreat residents, with a particular focus on withholding of food or medication, understaffing shifts, the use of physical and chemical restraints, and inadequate infection control practices.

As part of a broader initiative to combat elder fraud and abuse, Barr announced that approximately 30 nursing facilities in nine states are under investigation and cited facilities that were “unfit for living.” Particularly in an election year, this new initiative could lead to a significant expansion of civil fines and criminal penalties to shine a bright light on fraudulent and abusive practices and substandard facilities in the nursing home space. Although this initiative only purportedly covers nursing homes, there is some concern that the initiative could also expand to elder abuse and neglect in the broader long-term care arena, such as assisted living, home health and even skilled facilities in the future.

This announcement also confirms reports from last fall that the DOJ was making a push to more aggressively identify civil and criminal charges to be brought against the nation’s 15,000+ nursing homes and confluence with the expansion of False Claims Act actions in this space as well. In early 2019, a large long-term care system agreed to pay more than $18 million to settle False Claims Act liability related to the submission of claims to government payors for services provided to Medicare and Medicaid beneficiaries, alleging the underlying services were “grossly substandard or worthless.” Particularly, the DOJ alleged, in part, that five nursing facilities “failed to administer medications as prescribed; failed to provide standard infection control, resulting in urinary tract infections and wound infections; failed to provide wound care as ordered; failed to take prophylactic measures to prevent pressure ulcers, such as turning and repositioning; used unnecessary physical restraints on residents; and failed to meet basic nutrition and hygiene requirements of residents.”

This attention by the DOJ on personal liability for substandard services is not new, but represents a greater or reinvigorated focus on issues that continue to plague the industry. Over the better part of the past decade, the DOJ has taken an aggressive stance on enforcement against owners and operators of nursing homes giving poor care and providing improper services. In 2012, a Georgia nursing home operator was sentenced to 20 years in federal prison and ordered to pay more than $7 million in restitution to the government when surveyors found food shortages, poor sanitary conditions, staff shortages and other resident safety concerns in his facility. In 2019, a Miami-based owner of a chain of assisted-living and nursing home facilities was sentenced to 20 years in prison for accepting kickbacks and paying bribes to obtain improper referrals and provide unnecessary services (including mental health and prescription drug services) to Medicare and Medicaid beneficiaries.

Barr emphasized that “[t]he Initiative will bring to justice those owners and operators who put profits before patients, and it will help to ensure that the residents receive the care to which they are entitled.” The 2019 long-term care system settlement referenced above included $250,000 of additional fines brought against the system’s majority owner and former director of operations to further emphasize DOJ’s renewed focus on personal liability.

In addition to providing quality care to their residents, nursing homes and other long-term care facilities should closely scrutinize the areas for improvement the DOJ identified in its recent prosecutions cited above, as well as in its March 3 announcement. Specifically, Barr recounted a number of “horrifying examples” of mistreatment in his speech, where the DOJ and HHS found gaps in facility pest control, infection control and hygienic practices; poor care indicators such as resident pressure ulcers, pain and infections; and physical facility, resident nutrition and insufficient staffing levels. The DOJ may also more closely monitor areas of elder fraud, including manipulation or theft from resident trust accounts.

For lenders, private equity or other investors in this space, it is important to consider conducting robust diligence related to these issues, such as reviewing and understanding where these issues may come to light through the survey process and patient or family complaints, as they have the potential to significantly impact business from both financial and reputational perspectives. For those already invested, in addition to the increased scrutiny and potential for a government investigation in existing portfolio companies, consideration should be given to appropriately tracking and monitoring survey, complaint and potential related litigation matters to better anticipate issues and understand the steps being taken to mitigate the risks.

For questions or assistance on how this new approach may affect your facility, read about and contact McGuireWoods’ healthcare team.

Defense Arguments

Value-Based Purchasing and the False Claims Act: Tenth Circuit Finds Falsified Quality Data Immaterial Under Escobar

Last month, the Tenth Circuit upheld a grant of summary judgment in U.S. ex rel. Janssen v. Lawrence Memorial Hospital, 2020 WL 594508 (10th Cir. Feb. 7, 2020), applying the  “rigorous” and “demanding” standard of materiality for False Claims Act (“FCA”) cases established by the Supreme Court in Escobar.  In Janssen, the relator alleged that Lawrence Memorial Hospital (“LMH”) violated the FCA by (i) falsifying patient arrival times to maximize its Medicare reimbursement and (ii) falsely certifying compliance with Deficit Reduction Act (“DRA”) training requirements.  In a case of first impression on whether quality metrics reported to the Centers for Medicare and Medicaid Services (“CMS”) under certain programs can lead to FCA liability, the Tenth Circuit focused on the government’s “likely reaction” to the falsehoods, and found that the alleged non-compliance did not satisfy Escobar’s materiality standard.

Patient Arrival Times

The relator alleged that LMH intentionally falsified data that it reported under CMS’s Inpatient Quality Reporting (“IQR”), Outpatient Quality Reporting (“OQR”) and Hospital Value Based Purchasing (“HVBP”) programs to obtain higher Medicare reimbursement.  The IQR and OQR programs reward hospitals that report certain inpatient and outpatient quality measures with a market basket index increase, and penalize hospitals that do not report the data with a market basket index reduction.  The HVBP program adjusts payments to hospitals based on their overall performance score on certain quality metrics, including certain IQR measures.  Some of these measures incorporate patient arrival times (e.g., a patient receiving primary surgical intervention within 90 minutes of arrival).  The relator alleged that LMH falsified patient arrival times to maximize its quality scores under the IQR, OQR, and HVBP programs, which would affect its Medicare reimbursement. It did so, according to the relator and witness statements, by manipulating the arrival time to match the time the patient received an EKG.  While the Tenth Circuit agreed that a “reasonable inference” from the evidence was that LMH falsified some patient arrival times and reported inaccuracies to CMS, it determined that these falsehoods were not material under Escobar using a three-part analysis.

First, the court found that the government’s prior conduct in the case weighed in favor of immateriality.  The relator reported the inaccurate quality data reporting to a CMS fraud hotline in 2013, which triggered an investigation by a CMS contractor, NCI AdvanceMed (“NCI”).  In 2014, NCI closed its investigation, stating that “CMS [was] aware of the quality issue.”  The court noted that to date, CMS has not taken any action against LMH and has continued to pay Medicare claims despite knowing of the alleged falsifications.  The court found that CMS’ “inaction in the face of detailed allegations from a former employee suggests immateriality.”

The court continued its materiality analysis by looking at whether the alleged misconduct was “minor or insubstantial” or went “to the essence of the bargain” with the government.  The court noted that the alleged misconduct was limited and “affected only a subset of a subset” of the IQR and OQR data, and had “uncertain effects on a factor of a factor” of LMH’s performance score under the HVBP program.  While the court agreed that accurate reporting was arguably required, the court found that the minimal nature of the inaccuracies in LMH’s reported data did not go to the “essence of the bargain” between the hospital and CMS, and were therefore immaterial.  Importantly, the court noted that CMS’ existing regulatory regime establishes administrative procedures to address noncompliance with requirements of the IQR and OQR programs, and that substituting FCA liability would improperly render the FCA “a tool for policing minor regulatory compliance issues, contrary to the Court’s directive in Escobar.”

Finally, the court considered the relator’s argument that the government requires accurate reporting as a condition of payment under the IQR, OQR, and HVBP programs.  The court found that the statutory and regulatory provisions related to the programs were generic, and even if they did require accurate reporting as an express condition of payment, that alone is insufficient to establish materiality under Escobar.

DRA Compliance

The relator separately argued that LMH falsely certified its compliance with certain DRA training requirements.  The DRA requires entities receiving $5 million or more in annual Medicaid payments to educate employees on the FCA, specifying that any employee handbooks contain a specific discussion of the FCA and other laws.  The relator alleged that LMH’s employee handbooks lacked a detailed discussion of the FCA, and that LMH falsely signed Attestations of Compliance with the DRA.  The Tenth Circuit found this noncompliance to be immaterial as well, and that failure to have specific language in an employee handbook is “precisely the type of garden-variety compliance issue[] that the demanding materiality standards of the FCA are meant to forestall.”

Key Takeaways

The Janssen case provides a helpful framework for challenging FCA allegations using Escobar’s “rigorous” and “demanding” materiality standard, particularly highlighting the importance of the government’s knowledge of the non-compliant behavior and whether that non-compliance goes to the “essence of the bargain” with the government.  The Janssen case demonstrates that under the complex and technical regulatory environment that governs the Medicare and Medicaid programs, “not every regulatory foot-fault” will give rise to FCA liability.

FCA Litigation

3rd Circuit Case of First Impression Clarifies Lower Threshold for FCA Actions

Government contractors should take note of a March 4, 2020, ruling by the 3rd U.S. Circuit Court of Appeals (Court) that lowers the jurisdictional threshold for establishing a claim under the False Claims Act (FCA).

The 3rd Circuit’s decision in Druding v. Care Alternatives revived an FCA claim that the U.S. District Court for the District of New Jersey rejected through a grant of summary judgment. At the lower court, experts retained by the plaintiff and defendant disagreed about the factual basis of the alleged false claim. Confronted by this disagreement, the District Court ruled that “a mere difference of opinion between experts regarding the accuracy” of the claim at issue was “insufficient to create a triable dispute of fact as to the element of falsity.” The District Court opined that to meet the jurisdictional threshold, a plaintiff under the FCA must provide “evidence of an objective falsehood.” The appeals Court overturned the District Court’s finding that a viable claim must include evidence of an objective falsehood, instead finding that a dispute among the parties’ experts is enough to establish the basis of a triable claim because the expert’s testimony created a “genuine dispute of material facts as to the element of falsity.”

This case of first impression in the 3rd Circuit will allow more FCA cases to avoid early dismissal in the District Court, including those brought by qui tam relators, such as former employees. Relators are encouraged to bring qui tam actions because they are entitled to a portion of the recovered amount, subject to certain limitations. The Court reasoned that “[l]imiting falsity to factual falsity is inconsistent with our case law, which reads FCA falsity more broadly as legal falsity, encompassing circumstances where a claim for reimbursement is non-compliant with requirements under the statute and regulations.”

Government contractors, healthcare entities and other heavily regulated industries are encouraged to be proactive in mitigating the risk of enforcement actions, including through the maintenance of a robust Governance, Risk, and Compliance (GRC) internal infrastructure. McGuireWoods assists clients in gap analysis and remediation of compliance systems, audit support and FCA litigation defense. Proactive mitigating steps are especially important in areas where noncompliance includes high penalties, such as the potential for treble damages under the FCA statute.

This case creates a split of opinion among the circuits. The District Court opinion that was overturned applied the falsity standard adopted by the 11th Circuit in United States v. AseraCare, Inc., 938 F.3d 1278 (11th Cir. 2019); United States v. AseraCare Inc., 176 F. Supp. 3d 1282 (N.D. Ala. 2016); and United States v. AseraCare Inc., 153 F. Supp. 3d 1372 (N.D. Ala. 2015). McGuireWoods will monitor and report updates, including a potential Supreme Court resolution.

For questions or assistance, read about and contact McGuireWoods’ Government Contract Investigations and Enforcement team, McGuireWoods’ Government Contracts team, and/or Healthcare team.

McGuireWoods’ Government Investigations & White Collar Department is a nationally recognized team of nearly 60 attorneys representing Fortune 100 and other companies and individuals in the full range of civil and criminal investigations and enforcement matters at both the federal and state level. Our team is comprised of a deep bench of former senior federal officials, including a former Deputy Attorney General of the United States, former U.S. Attorneys, more than a dozen federal prosecutors, and an Associate Counsel to the President of the United States. Strategically centered in Washington, DC, our Government Investigations & White Collar Litigation Department has been honored as a 2019 Law360 Practice Group of the Year and earned the trust of international companies and individuals through our representation in some of the most notable enforcement matters over the past decade.

Uncategorized

Federal Court Upholds CMS’ Use of Extrapolation to Claw-Back Improper Payments

A recent federal court decision should serve as an important reminder to providers that the Centers for Medicare and Medicaid Services (“CMS”) and its contractors have substantial authority to audit provider Medicare claims and to broadly apply extrapolation to calculate overpayments. In Palm Valley Health Care, Inc. v. Azar, No. 18-41067, 2020 BL 14097 (5th Cir., Jan. 15, 2020), the United States Court of Appeals for the Fifth Circuit re-affirmed CMS’ application of extrapolation of errors identified in a sample of claims to over 10,000 claims. The resulting demand for the provider, Palm Valley Health Care, Inc. (“Palm Valley”), to refund claims was $12 million rather than the amounts paid on the sample set. Providers need to be aware that when CMS audits their claims, CMS is not required to use the most precise statistical methodology for selecting claims for audit.

Background on CMS Audits and the Application of Extrapolation

As part of its oversight obligations, CMS, through its Medicare Administrative Contractors and other contractors, audits claims submitted for payment to ensure the claims comply with Medicare billing requirements. When CMS determines that it made a payment to a provider for services that were “medically unnecessary or incorrectly billed”, an “actual overpayment” will be deemed to have occurred and CMS will seek a refund of the overpayment from the provider.

Because Medicare cannot conduct a comprehensive review of every claim submitted for payment to ensure it complies with billing requirements, Congress has authorized CMS to use statistical sampling and apply extrapolation when “there is a sustained or high level of payment error.” [1]  Significantly, the Medicare Program Integrity Manual (the “Manual”), which was amended considerably with respect to extrapolation in 2019, provides a broad array of general factors that the contractor “shall” use in order to determine that “a sustained or high level of payment error” has occurred. These factors include but are not limited to:

  1. High error rate determinations by the contractor or by other medical reviews (i.e., greater than or equal to 50 percent from a previous pre- or post-payment review);
  2. Provider/supplier history (i.e., prior history of non-compliance for the same or similar billing issues, or historical pattern of non-compliant billing practices);
  3. CMS approval provided in connection to a payment suspension;
  4. Information from law enforcement investigations;
  5. Allegations of wrongdoing by current or former employees of a provider/supplier; and/or
  6. Audits or evaluations conducted by the Office of Inspector General (“OIG”).[2]

A contractor can also identify reasons beyond those listed above as a basis for using extrapolation (e.g., billing for non-covered services, billing for services not rendered) although those decisions are subject to further review within CMS.[3]

Palm Valley’s Targeted Audit with Extrapolation

In Palm Valley, CMS’s contractor, Palmetto GBA, LLC (“Palmetto”), conducted a targeted audit of Medicare claims submitted by Palm Valley for the period of July 1, 2006 through January 31, 2009. According to CMS, Palm Valley was selected for an audit because it had submitted an unusually high number of claims (10,699) for the period at issue. For the audit, CMS employed a methodology that resulted in 54 claims being selected for review. CMS’ review of those claims determined that 29 claims were not eligible for payment by Medicare because the beneficiaries’ records did not satisfy Medicare’s requirements for eligibility for home health care.

The overpayment for those 29 claims totaled $81,681 but more significantly, the 29 claims represented a 53.7% error rate based on the 54 total claims selected for audit. With this error rate, CMS used extrapolation based on its determination that there had been a “sustained or high level of payment error.” After the administrative appeals process, which overruled the contractor on four claims, by using extrapolation on the remaining 25 claims, Palm Valley was required to repay $12,589,185 to CMS.

CMS Has Substantial Authority to Select Statistical Methods in Extrapolation

Although Palm Valley primarily sought judicial review over whether the denied claims complied with Medicare’s billing requirements for home health care, Palm Valley also challenged CMS’ sample and extrapolation methodology. Palm Valley argued that CMS’ selection of 54 claims out of 10,669—in other words a mere 0.0051% of the total claims Palm Valley submitted during the period at issue was too imprecise of a sample to rely on. After relying upon statutory language to note that the decision that there is a “sustained or high level of payment error” is not reviewable, the court examined the merits of Palm Valley’s argument. The court quickly dismissed it, noting that while the statistical sampling methodology may not be the most precise methodology available, CMS’ selection methodology did represent a valid “complex balance of interests.” Principally, the court noted, quoting the Medicare Appeals Council, that CMS’ methodology was justified by the “real world constraints imposed by conflicting demands on limited public funds” and that Congress clearly envisioned extrapolation being applied to calculate overpayments in instances like this.

While the court suggested it agreed with Palm Valley’s contention that a more precise formula may result in a more precise calculation for extrapolation, the court held that the law merely requires CMS to apply a statistically valid formula—which may not be the most precise formula. Even Palm Valley’s own expert had testified that CMS’ formula was statistically valid. Further, the court held that at a minimum CMS’ methodology provided “substantial evidence” to support CMS’ decision to require Palm Valley to refund claims which did not satisfy Medicare’s billing requirements. The court further noted that, if anything, it believed the extrapolation methodology was “provider friendly” in that CMS’ formula gives the provider substantial benefit of doubt—CMS’ formula assumes that the average overpayment for all claims is equal to a number that there is a 90% chance is smaller than the actual overpayment. Therefore, the court concluded that there was a 90% chance that Palm Valley’s overpayment liability was in fact greater than the $12 million that CMS had determined Palm Valley owed.

Lessons for Providers

While all providers will routinely be required to refund claims that do not satisfy Medicare billing requirements, providers need to be cognizant that sustained billing errors substantially increase their risk for significant audits and refund demands. Providers need to make sure that they not only understand and abide by Medicare’s billing requirements when providing care but also that their documentation supports their claims. This documentation is important not only to make sure the claim is paid upon submission but also to make sure the claim will sustain CMS’ scrutiny if the provider is selected for an audit. Taking relatively small proactive steps during the course of providing care and billing for services can help providers avert potentially financially devastating refunds down the road.

[1] 42 U.S.C. § 1395ddd(f)(3)(A).

[2] Medicare Program Integrity Manual § 8.4.1.4.

[3] Id.

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