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Primary Care Providers Win Challenge of CMS Interpretation of Enhanced Payment Law

With the help and support of the Tennessee Medical Association, 21 Tennessee physicians of underserved communities joined together and retained Bass, Berry & Sims to file suit against the Centers for Medicare & Medicaid Services to stop improper collection efforts. Our team, led by David King, was successful in halting efforts to recoup TennCare payments that were used legitimately to expand services in communities that needed them. Read more

Tennessee Medical Association & Bass, Berry & Sims

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Download the Healthcare Fraud & Abuse Review 2017, authored by Bass, Berry & Sims

The Healthcare Fraud & Abuse Review 2017 details all healthcare-related False Claims Act settlements from last year, organized by particular sectors of the healthcare industry. In addition to reviewing all healthcare fraud-related settlements, the Review includes updates on enforcement-related litigation involving the Stark Law and Anti-Kickback Statute, and looks at the continued implications from the government's focus on enforcement efforts involving individual actors in connection with civil and criminal healthcare fraud investigations.

Click here to download the Review.

Middle District of Tennessee Clarifies Pleading Standards for the Presentment of False Claims

Publications

November 25, 2015

Earlier this month, the U.S. District Court for the Middle District of Tennessee dismissed a relator's qui tam lawsuit, finding that the relator had failed to adequately allege the presentment of false claims to the government. In U.S. ex rel. Prather v. Brookdale Senior Living, Inc., the relator alleged that Brookdale submitted false claims for home health services that did not meet the technical requirements for billing under Medicare rules and regulations. Defendants argued that the allegations failed to include sufficient detail regarding the actual submission of requests for anticipated payment (RAP) claims and that the relator failed to plead the requisite legal falsity of both RAP and final episode payment claims.

The district court dismissed the second amended complaint with prejudice, finding that the relator did not meet the "strict requirement" that she allege the submission of actual false claims to a federal healthcare program. The district court found that despite including information regarding treatment dates, the entity providing the treatment, and the Brookdale community at which the patient resided for four exemplar patients and several hundred patients in attached exhibits, the complaint failed to allege the presentment of any false claim. The district court held that it was "insufficient for Prather to point to a patient that received home health care services and allege that a RAP was, or must have been, submitted, by some corporate authorization, for some amount, at some date around the date of treatment, and that some payment was likely received in return from the government, based just on the generally delineated circumstances of the patient's receipt of home health services from a defendant entity." The information provided was "too general and too attenuated from the Medicare Billing process to satisfy the requirements of the law concerning the presentment of specific false claims."

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