In a unanimous vote, the Supreme Court revived two False Claims Act cases involving improper pharmaceutical billing, signaling a win for whistleblowers and disappointing hospital and physician groups.
Doctors, hospitals, and pharmacies are often charged with FCA violations in, but they say the rules are unclear and that as a result, they are being sanctioned when there was no intent to defraud. Whistleblowers say organizations try to justify fraud by using post facto"explanations" for the way they bill.
Under the FCA, a person is liable when they knowingly submit false claims or suspect the claim is incorrect but neglect to verify the information, something the law refers to as reckless disregard and deliberate ignorance. Violators must pay three times the government's damages plus an. As a deterrence of healthcare fraud, individuals can file an action on behalf of the United States and receive a portion of the recovery .
Both cases had previously been heard in district court. In those cases, the FCA threshold was not met because the pharmacies could not have acted"knowingly" because at that time, there was no authoritative guidance from Medicaid and Medicare about reimbursement of discounted pricing models, the lower courts ruled.
"What matters now is what are you thinking when you bill the government," said Johnson. Providers and hospitals involved in FCA disputes may have to go through expensive and time-consuming discovery processes to determine that information, which will now be necessary in the SuperValu and Safeway cases. Regardless, he said medical billing will be"under more scrutiny than ever" and that the impact on industry will be similar to that of electronic medical records.
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