Challenging Physician Judgment: Is Your Institution Exposed to False Claims Act Liability?
A case recently appealed to the Supreme Court could subject healthcare providers to increased liability under the FCA regarding certifications of medical necessity for services they bill for. For example, CMS only pays for hospice services if physicians certify that the patient is expected to live six months or less, but CMS has indicated that a physician need not worry about liability due to challenges to their good faith clinical judgment.
Care Alternatives v. United States brings that holding into question, with the Third Circuit determining that a physician’s medical judgment could be deemed “false” for purposes of liability. The Fourth, Seventh, Tenth, and Eleventh Circuits have ruled otherwise, while the Ninth Circuit has ruled similarly to the Third. This split is the basis for Care Alternatives’ appeal.
