Partner Christopher Donovan was quoted in the Report on Medicare Compliance article, “In AseraCare FCA Case, Court Says a Contrary Medical Opinion Is Not Enough,” about the long-awaited 11th U.S. Circuit Court of Appeals decision in the AseraCare, Inc. false claims act case about what is required to prove false claims beyond a physician disputing the eligibility of Medicare services after the fact.
The FCA suit against AseraCare was set in motion by three former employees of the company. The Department of Justice intervened, filing its own complaint, which alleged that AseraCare submitted documentation that supported Medicare claims for hospice patients who were not terminally ill.
The 11th Circuit held that it takes more than a physician disputing eligibility to prove false claims, but also gave the DOJ another chance to take AseraCare to trial with the caveat that it needs to do more than “expert armchair quarterbacking.”
Donovan said the ruling is mostly good news for providers on the medical necessity and FCA fronts. “Providers have always been comfortable with the statement that if clinicians make good-faith judgments about the eligibility of of a patient for a particular service, as long as that judgment was in good faith, it would be second guessed afterward. The court agreed with that,” Donovan said. “You can’t just roll out another expert who disagrees with your certification.”
Read the full article here.