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Healthcare Providers Need To Ensure Compliance Under Expansion of False Claims Act

False Claims Act Attorney The U.S. Supreme Court voted unanimously to allow False Claims Act (FCA) liability under the “implied certification theory.”

The implied certification theory means that submitting a claim to the government implies that the entity has complied with all contractual and regulatory requirements.

What The Supreme Court Ruling Means To Healthcare Providers

This decision could have profound repercussions for healthcare providers who bill federal healthcare programs. Healthcare providers must contend with the Stark Law and Anti-Kickback Statute (“AKS”). Violations of either the Stark law or AKS give rise to FCA liability. Healthcare cases make up approximately two-thirds of federal whistle-blower cases, which are enforced using the FCA.

The Supreme Court did not limit liability under the implied certification theory to conditions of payment. This ruling can potentially mean that a facially valid invoice can violate the false claims act case because of requirements that are not explicitly requirements for payment. If a regulation is a condition of participation but not a condition of payment, a violation can still give rise to FCA liability.

The Supreme Court did rule that liability is limited to “material” violations. Materiality may be shown if it is a provision for which the government routinely denies payment. The Court emphasized that the materiality test is “rigorous” and demanding….”

Healthcare Providers Need To Ensure Compliance 

Healthcare providers, and all contractors billing the government, should ensure they are compliant with all statutory, regulatory and contractual requirements.

Jeyaram & Associates’ attorneys have extensive experience in helping healthcare providers remain compliant with all state and federal regulations. Contact DJ Jeyaram at or Jonathan Anderson at

Healthcare Providers Need To Examine Billing Practices To Ensure Compliance

healthcare fraudLast month, the Department of Health and Human Services released its annual report for the Health Care Fraud and Abuse Control Program. According to the report, in 2014 more than 900 new criminal health care fraud investigations were opened by the Department of Justice. There was a slight increase in the number of criminal cases and convictions from last year, with 496 cases and 735 defendants convicted of criminal health care fraud. Civil cases alone resulted in $2.3 Billion in settlements and judgments.

The government’s press release reiterated that detecting and eliminating fraud and abuse continues to be a top priority. The government attributes its high recoveries to a change in strategy which uses real-time data analysis to detect fraud more quickly. The Centers for Medicare and Medicaid currently uses advanced analytics on Medicare fee-for-service claims. The goal of this is to detect aberrant and suspicious billing patterns which would then trigger an investigation or enforcement action by the government.

Now is the time to for Medicare and Medicaid providers to review their billing practices and financial relationships to ensure that they are compliant with federal laws. Charges against providers were made under the False Claims Act, as well as Anti-Kickback Statute, the Stark Law (Physician Self-Referral Law), and other federal laws.

The full annual report is available at

If you have any questions about the legality of your billing practices or financial relationships, please contact DJ Jeyaram at or Danielle Hildebrand at