There are a number of key issues that will drive the government's enforcement efforts in the coming year and that will have a significant impact on how healthcare fraud matters are pursued by relators asserting FCA claims and are defended on behalf of healthcare providers. In the coming weeks, we will examine these issues in greater depth and why healthcare providers should keep a close eye on these issues. This week, we examine the future of implied certification as a viable FCA theory of falsity.
In December 2015, the U.S. Supreme Court granted the petition for writ of certiorari in Universal Health Services, Inc. v. Escobar and will consider whether and to what extent the implied certification theory is a viable theory of falsity under the FCA. This case undoubtedly will be one of the most closely watched FCA cases to be argued before the Supreme Court since the 1986 amendments to the FCA.
In the absence of a statutory definition of "falsity," courts have grappled with how to define the FCA's reach in determining what constitutes a false or fraudulent claim. To this end, a number of courts have fashioned distinctions between "factually" false and "legally" false claims and have further subdivided "legally" false claims based on whether those claims are premised on "implied" or "express" certification of compliance with conditions of payment. See, e.g., U.S. ex rel. Conner v. Salina Reg'l Health Ctr., Inc., 543 F.32d 1211, 1217 (10th Cir. 2008).
To complicate things further, there is a division among some courts regarding whether the conditions of payment upon which an implied certification theory of liability must be expressly identified as such. Compare Chesbrough v. VPA, P.C., 655 F.3d 461, 468 (6th Cir. 2011); Mikes v. Straus, 274 F.3d 687, 702 (2d Cir. 2001), with U.S. ex rel. Hutcheson v. Blackstone, 647 F.3d 377, 386-88 (1st Cir. 2011); U.S. ex rel. Triple Canopy, Inc., 775 F.3d 628, 636 (4th Cir. 2015); U.S. ex rel. Davis v. SAIC, 626 F.3d 1257, 1269-70 (D.C. Cir. 2010).
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