James Hafner

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In a decision that will impact every provider who supplies goods and services to the federal government, the Supreme Court today approved the implied false certification theory as a basis for liability under the False Claims Act (FCA). Specifically, in Universal Health Services v. Escobar, the Court ruled that the FCA is violated whenever a provider submits a claim for payment to the government yet misrepresents its compliance with material statutory, regulatory or contractual requirements—whether…
In a move that could affect all hospitals reimbursed by Medicare, the American Hospital Association (AHA) this week renewed strenuous objections to various aspects of ongoing hospital compliance reviews conducted by the Department of Health and Human Services (HHS) Office of Inspector General (OIG). AHA’s most recent correspondence references the “numerous legal defects” it had previously identified in OIG’s hospital audits. These defects include claims that OIG audits (1) waste HHS resources and are unduly…
Yesterday, in a blow to the Obama Administration, the United States District Court for the District of Columbia struck down a key ACA provision designed to reduce insurance costs. Specifically, Section 1402 of the ACA requires insurers participating in the Exchanges to reduce deductibles, coinsurance, copayments, and other means of cost-sharing on qualified health plans. Rather than stick insurers with the bill, the ACA provides that the federal government will subsidize these costs (estimated at…
This week, the United States Supreme Court heard oral arguments in Universal Health Services v. United States ex rel. Escobar, a case destined to influence the scope of False Claims Act (FCA) liability for anyone who receives payments from Medicare, Medicaid or any other federal government-funded health care program. As Justice Breyer acknowledged during oral argument, “billions of dollars” are “at issue.” During oral argument, the Justices seemed likely to accept the implied certification theory…
Beginning in January 2017, primary care physicians and their practices (PCPs)  will be able to participate in a multi-payer payment reform and care delivery transformation aimed at strengthening primary care. Dubbed the Comprehensive Primary Care Plus (CPC+) initiative, the recently unveiled primary care medical home model is CMS’s latest effort to encourage value-based payment methodology, with an aim towards promoting health and reducing overall health care costs. In an effort to encourage PCP participation in…
On March 30, 2016, the US Department of Justice (DOJ) announced that healthcare providers who serve the elderly in the following 10 states will have task forces looking over their shoulders: California, Georgia, Kansas, Kentucky, Iowa, Maryland, Ohio, Pennsylvania, Tennessee and Washington. Known as the Elder Justice Task Forces (Task Forces), these partnerships combine the resources of “federal, state and local prosecutors, law enforcement, and agencies that provide services to the elderly,” with an eye…
Overview After receiving scores of comments over nearly 4 years, the Centers for Medicare and Medicaid Services (CMS) has released its final rule (the “Final Rule”) addressing the reporting and returning of overpayments made to suppliers and providers who receive funds through Medicare. The Final Rule implements Section 6402(a) of the Affordable Care Act, which requires that suppliers and providers report and return overpayments by 60 days after (1) the overpayment is identified or (2)…
Telemedicine, Follow-Up Care and State Licensure: The Problem Illustrated As the delivery of healthcare services adapts to the digital age, providers, payers and patients are gradually exploring telemedicine’s possibilities. Evidence that delivering certain routine services via telemedicine may increase patient access to care and decrease cost without sacrificing quality has only served to accelerate this trend. One particular area would seem a natural candidate for telemedicine services: post-op follow-up care performed on a patient who…