U.S. Supreme Court Explains Liability Under False Claims Act for Payment of Medical Services to Unlicensed Providers

Erin Medeiros

The United States Supreme Court recently provided further guidance on pleading a valid claim(s) under the False Claims Act (“FCA”) in a case named United Health Services, Inc. v. United States, et al., 579 U.S. ____ (2016).   The focus of the FCA remains on all federal government contractors “who present or directly induce the submission of false or fraudulent claims” to the federal government.  Such a claim includes requests for payment and reimbursements for recipients of federal benefits, such as Medicaid and Medicare.

In United Health Services, the Supreme Court held that an implied false certification theory of liability can be a basis for FCA liability.  False certification liability is “failing to disclose violations of legal requirements that does not turn upon whether those requirements were expressly designated as conditions of payment.”  At issue in the case was a claim that, United Health Services, Inc. (“UHS”) submitted claims for payment to Medicaid for providers who were not properly licensed and/or supervised under state law to provide services to UHS’ patients; such submitted claims were paid by the federal government.

The implied false certification theory of liability “treats a contractor’s request for payment from the government as the contractor’s implied certification of compliance with relevant statutes, regulations, or contract requirements that are material conditions of payment and treats a failure to disclose a violation as a misrepresentation,” making the claim false or fraudulent.  The Court stated that such a theory is met and liability assigned where 1) the claim requests payment and includes “specific representations about the goods or services provided;” and 2) the claimant’s “failure to disclose noncompliance with material statutory, regulatory, or contractual requirements makes those representations misleading half-truths.”  The adoption by the Supreme Court of this theory of liability is significant for FCA plaintiffs.

If your employer has asked you or your co-workers to bill for services for which you did not provide or were not properly licensed or supervised, and your employer has submitted claims for those services to Medicaid or Medicare, you may have a claim under the FCA.  The FCA provides that an individual can bring a lawsuit for submission of false or fraudulent claims.  Any award in such FCA lawsuit is proportioned between the individual and the federal government.  If you have any questions concerning improper Medicare or Medicaid billing under the FCA, please contact The Previant Law Firm, S.C. Call (414) 240-1185, or visit our website