SLIDE 1
Malpractice or Fraud? The False Claims Act and Quality of Care Issues
1
Malpractice or Fraud? The False Claims Act and Quality of Care Issues
Dan Mulholland Horty, Springer & Mattern
False Claims Act Theories Based on Quality
- Lack of medical necessity
- “Worthless” services
- Negligent or “substandard” care
- Violation of regulations
Medical Necessity
Medicare only pays for services that are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”
42 U.S.C. §1395y(a)(1)(A)
Worthless Services
“In a worthless services claim, the performance of the service is so deficient that for all practical purposes it is the equivalent of no performance at all.”
Mikes v. Straus, 274 F.3d 687, 703 (2d Cir. 2001)
Negligent or Substandard Care
“permitting qui tam plaintiffs to assert that defendants’ quality of care failed to meet medical standards would promote federalization of medical malpractice, as the federal government or the qui tam relator would replace the aggrieved patient as plaintiff.”
Mikes v. Straus, 274 F.3d 687, 701 (2d Cir. 2001)
Violation of Regulations
- Conditions of Payment?
- r
- Conditions of Participation?