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Volumn 26, Issue 1, 2000, Pages 69-88

First nursing homes, next managed care?: Limiting liability in quality of care cases under the false claims act

(1)  Peterson, Kathleen A a  

a NONE

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; GOVERNMENT; HEALTH CARE QUALITY; HEALTH INSURANCE; LAW; LAW SUIT; MALPRACTICE; MANAGED CARE; MEDICAID; MEDICAL LIABILITY; MEDICARE; NEGLIGENCE; PATIENT; PHYSICIAN; UNITED STATES;

EID: 0034058942     PISSN: 00988588     EISSN: None     Source Type: Journal    
DOI: 10.1017/s0098858800010820     Document Type: Article
Times cited : (4)

References (194)
  • 1
    • 85212260825 scopus 로고    scopus 로고
    • note
    • In Hall v. Hilbun, 466 So. 2d 856 (Miss. 1985), the Supreme Court of Mississippi explained that: Medical malpractice is legal fault by a physician or surgeon. It arises from the failure of a physician to provide the quality of care required by law. . . . Each physician . . .has a duty of care consistent with the level of expertise the physician holds himsef out as possessing and consistent with the circumstances of the case. That duty is non-delegable. It is owing to each patient he or she undertakes to treat, and in that regard the patient has a correlative right. Injury caused by substantial violations of the physician's duty and the patient's right may subject the physician to tort liability. Liability turns on a failure to provide the required level of care. It matters not whether this failure results from incompetence or negligence. Id. at 869.
  • 2
    • 0343339135 scopus 로고    scopus 로고
    • A Managed Care Organization's Medical Malpractice Liability for Denial of Care: The Lost World
    • See generally Jose L. Gonzalez, A Managed Care Organization's Medical Malpractice Liability for Denial of Care: The Lost World, 35 HOUS. L. REV. 715 (discussing theories of managed care liability for denying care).
    • Hous. L. Rev. , vol.35 , pp. 715
    • Gonzalez, J.L.1
  • 3
    • 85031757803 scopus 로고    scopus 로고
    • Establishment of the Medicare+Choice Program
    • Under the Medicare+Choice program, participants may use their Medicare funds to enroll inmanaged care plans. See Medicare Program; Establishment of the Medicare+Choice Program, 63 Fed.Reg. 34,968, 34,968-69 (1998) (codified at 42 C.F.R. pts. 400, 403, 410, 411, 417 & 422).
    • (1998) Fed.Reg. , vol.63 , pp. 34968
  • 4
    • 85212254368 scopus 로고    scopus 로고
    • See 31 U.S.C.A. § 3730(b)(1) (West 1999)
    • See 31 U.S.C.A. § 3730(b)(1) (West 1999).
  • 5
    • 85212260762 scopus 로고    scopus 로고
    • See id. § 730(c)(1)
    • See id. § 730(c)(1).
  • 6
    • 85212263387 scopus 로고    scopus 로고
    • See id. § 3730(d)
    • See id. § 3730(d).
  • 7
    • 85212273445 scopus 로고    scopus 로고
    • note
    • See id. § 3730(e)(4)(B) (defining "original source" as "an individual who has direct and independent knowledge of the information on which the allegations are based.").
  • 8
    • 0342469669 scopus 로고
    • Annotation, Validity, Construction, and Application of State Statutory Provisions Limiting Amount of Recovery in Medical Malpractice Claims
    • See generally Carol A. Crocca, Annotation, Validity, Construction, and Application of StateStatutory Provisions Limiting Amount of Recovery in Medical Malpractice Claims, 26 A.L.R.5th 245 (1995 & Supp. 1999) (discussing and analyzing various state medical malpractice damage limitationprovisions).
    • (1995) A.L.R.5th , vol.26 , Issue.1999 SUPPL. , pp. 245
    • Crocca, C.A.1
  • 9
    • 85212305746 scopus 로고    scopus 로고
    • 31 U.S.C.A. §§ 3729-33
    • 31 U.S.C.A. §§ 3729-33.
  • 10
    • 85212293169 scopus 로고    scopus 로고
    • See id. § 3730(d)
    • See id. § 3730(d).
  • 11
    • 85212251018 scopus 로고    scopus 로고
    • last modified Feb. 2
    • Office of the Inspector Gen., U.S. Dep't of Health & Human Services, "Who Pays? You Pay. ": Report Medicare Fraud (last modified Feb. 2, 2000) 〈http://www.hhs.gov/progorg/oei/outreach/outreach.htm〉.
    • (2000) "Who Pays? You Pay. ":Report Medicare Fraud
  • 12
    • 85212257268 scopus 로고    scopus 로고
    • See id.
    • See id.
  • 13
    • 85212308983 scopus 로고    scopus 로고
    • Id.
    • Id.
  • 14
    • 85212251598 scopus 로고    scopus 로고
    • See id.
    • See id.
  • 15
    • 85212292736 scopus 로고    scopus 로고
    • 42 U.S.C.A. §§ 1320a-3, a-4, a-5, a-7b, 1396k
    • 42 U.S.C.A. §§ 1320a-3, a-4, a-5, a-7b, 1396k.
  • 16
    • 85212277811 scopus 로고    scopus 로고
    • note
    • Id. §§ 1320a-7c, a-7d, a-7e, 1320d. Significantly, the Health Insurance Portability and Accountability Act of 1996 created the Health Care Fraud and Abuse Control Program. See id. §1320a-7c. This program was aimed at coordinating a national effort at all levels of government to combat health care fraud. See id. Covering everything from investigations of health care delivery, including creating a national databank compiling adverse fraud and abuse actions against providers, to creating new remedies and funding sources for anti-fraud efforts, this sweeping legislation is the impetus behind the "Who Pays? You Pay." program. See id.
  • 17
    • 85212257550 scopus 로고    scopus 로고
    • Id. § 1395nn
    • Id. § 1395nn.
  • 18
    • 85212256373 scopus 로고    scopus 로고
    • Dep't of Justice Health Care Fraud Rep.: Fiscal Year 1998
    • last modified Feb. 16, 2000
    • Id. § 1997. This list of statutes is by no means all-inclusive. For a discussion of several statutes the government uses to combat health care fraud, see generally U.S. DEP'T OF JUSTICE HEALTH CARE FRAUD REP.: FISCAL YEAR 1998 (1999), available in Health Care Fraud Report Fiscal Year 1998 (last modified Feb. 16, 2000) 〈http://www.usdoj.gov/dag/pubdoc/health98.htm〉 [hereinafter 1998 FRAUD REPORT]. See also Leon Aussprung, Fraud and Abuse: Federal Civil Health Care Litigation and Settlement, 19 J. LEGAL MED. 1, 5-17 (1998).
    • (1999) Health Care Fraud Report Fiscal Year 1998
  • 19
    • 0031948216 scopus 로고    scopus 로고
    • Fraud and Abuse: Federal Civil Health Care Litigation and Settlement
    • Id. § 1997. This list of statutes is by no means all-inclusive. For a discussion of several statutes the government uses to combat health care fraud, see generally U.S. DEP'T OF JUSTICE HEALTH CARE FRAUD REP.: FISCAL YEAR 1998 (1999), available in Health Care Fraud Report Fiscal Year 1998 (last modified Feb. 16, 2000) 〈http://www.usdoj.gov/dag/pubdoc/health98.htm〉 [hereinafter 1998 FRAUD REPORT]. See also Leon Aussprung, Fraud and Abuse: Federal Civil Health Care Litigation and Settlement, 19 J. LEGAL MED. 1, 5-17 (1998).
    • (1998) J. Legal Med. , vol.19 , pp. 1
    • Aussprung, L.1
  • 20
    • 85212281388 scopus 로고    scopus 로고
    • note
    • See 1998 FRAUD REPORT, supra note 18. The $12 billion figure, representing approximately seven percent of total Medicare fee-for-service spending in 1998, actually indicated a significant decline from previous years' estimates of wasteful spending. See id. For example, wasteful spending accounted for $20.3 billion (or 11%) of Medicare spending in fiscal year 1997, and $23.2 billion (or 14%) in fiscal year 1996. See id.
  • 21
    • 0343339123 scopus 로고
    • Note, The Qui Tam Provision of the Federal False Claims Act: The Statute in Current Form, its History and its Unique Position to Influence the Health Care Industry
    • See Carolyn J. Paschke, Note, The Qui Tam Provision of the Federal False Claims Act: The Statute in Current Form, its History and its Unique Position to Influence the Health Care Industry, 9 J.L. & HEALTH 163, 165 (1995).
    • (1995) J.L. & Health , vol.9 , pp. 163
    • Paschke, C.J.1
  • 22
    • 85212272696 scopus 로고    scopus 로고
    • available in last modified Nov. 20
    • See Memorandum from Eric H. Holder, Jr., Deputy Attorney General, Office of the Deputy Attorney General, to all United States Attorneys, all First Assistant United States Attorneys, all Civil Health Care Fraud Coordinators in the Offices of the United States Attorneys and all Trial Attorneys inthe Civil Division, Commercial Litigation Section 1, Jun. 3, 1998, available in Deputy Attorney General's FOIA Reading Room (last modified Nov. 20, 1998) 〈http://www.usdoj.gov/04foia/readingrooms/chcm.htm〉 [hereinafter Holder Memorandum] (referring to the False Claims Act (FCA)as "[o]ne of the Department's most important tools in protecting the integrity of Medicare and other taxpayer-funded health care programs"); Aussprung, supr e 18, at 5 (identifying the FCA as "[t]he primary and most frequently used statute in civil health care fraud").
    • (1998) Deputy Attorney General's FOIA Reading Room
    • Holder E.H., Jr.1
  • 23
    • 85212300008 scopus 로고    scopus 로고
    • See Aussprung, supra note 18, at 17-31
    • See Aussprung, supra note 18, at 17-31.
  • 24
    • 85212272035 scopus 로고    scopus 로고
    • note
    • United States ex rel. Pogue v. American Healthcorp, Inc., 914 F. Supp. 1507, 1508 (M.D. Tenn. 1996) (citing Young-Montenay, Inc. v. United States, 15 F.3d 1040, 1043 (Fed. Cir. 1994)). A debatable issue exists as to whether the FCA places an additional burden on plaintiffs to prove that the alleged false statements were material in that the government relied on them in making its funding decision. This issue will be addressed more completely infra Part V.B.-C.
  • 26
    • 85212282797 scopus 로고    scopus 로고
    • note
    • See United States ex rel. Thompson v. Columbia/HCA Healthcare, Corp., 125 F.3d 899, 902 (5th Cir. 1997); Pogue, 914 F. Supp. at 1509-12; Ab-Tech Constr., Inc. v. United States, 31 Fed. Cl.429, 434 (1994) (holding that a government contractor implicitly certified compliance with the Small Business Act in submitting payment vouchers), aff'd, 57 F.3d 1084 (Fed. Cir. 1995). But see United States ex rel. Joslin v. Community Home Health, 984 F. Supp. 374, 383-85 (D. Md. 1997) (rejecting the implied certification theory).
  • 27
    • 85212287600 scopus 로고    scopus 로고
    • See infra text accompanying note 29
    • See infra text accompanying note 29.
  • 28
    • 0030627223 scopus 로고    scopus 로고
    • The Role of the Federal Government in Ensuring Quality of Care in Long-Term Care Facilities
    • See David R. Hoffman, The Role of the Federal Government in Ensuring Quality of Care in Long-Term Care Facilities, 6 ANNALS HEALTH L. 147, 148 (1997), The FCA defines "claim" broadly as including: any request or demand, whether under contract or otherwise, for money or property which is made to a contractor, grantee, or other recipient if the United States Government provides any portion of the money or property which is requested or demanded, the Government will reimburse such contractor, grantee, or other recipient for any portion of the money or property which is requested or demanded. 31 U.S.C.A. § 3729(c) (West 1999).
    • (1997) Annals Health L. , vol.6 , pp. 147
    • Hoffman, D.R.1
  • 29
    • 0342904086 scopus 로고    scopus 로고
    • Comment, the False Claims Act and Managed Care: Blowing the Whistle on Underutilization
    • See Mary DuBois Krohn, Comment, The False Claims Act and Managed Care: Blowing the Whistle on Underutilization, 28 CUMB. L. REV. 443, 458 (1998).
    • (1998) Cumb. L. Rev. , vol.28 , pp. 443
    • DuBois Krohn, M.1
  • 30
    • 85212296635 scopus 로고    scopus 로고
    • note
    • See Paschke, supra note 20, at 165. The FCA currently defines "knowing" to mean that "a person, with respect to information - (1) has actual knowledge of the information; (2) acts in deliberateignorance of the truth or falsity of the information; or (3) acts in reckless disregard of the truth orfalsity of the information, and no proof of specific intent to defraud is required." 31 U.S.C.A. §3729(b).
  • 31
    • 0032326029 scopus 로고    scopus 로고
    • Medicare Fraud and Abuse and Qui Tam: The Dynamic Duo or the Odd Couple?
    • See Kaz Kikkawa, Medicare Fraud and Abuse and Qui Tam: The Dynamic Duo or the Odd Couple?, 8 HEALTH MATRIX 83, 86 (1998); Paschke, supra note 20, at 164.
    • (1998) Health Matrix , vol.8 , pp. 83
    • Kikkawa, K.1
  • 32
    • 85212302759 scopus 로고    scopus 로고
    • Paschke, supra note 20, at 164
    • See Kaz Kikkawa, Medicare Fraud and Abuse and Qui Tam: The Dynamic Duo or the Odd Couple?, 8 HEALTH MATRIX 83, 86 (1998); Paschke, supra note 20, at 164.
  • 33
    • 85212293723 scopus 로고    scopus 로고
    • See 31 U.S.C.A. § 3730(a) (West 1999)
    • See 31 U.S.C.A. § 3730(a) (West 1999).
  • 34
    • 85212263610 scopus 로고
    • Who sues on behalf of the King as well as forhimself
    • 6th ed.
    • See id. § 3730 (b)(1). "Qui tam" abbreviates the Latin phrase "qui tam pro domingo regequam pro si ipso in hoc parte sequitur" translated as "Who sues on behalf of the King as well as for himself." BLACK'S LAW DICTIONARY 1251 (6th ed. 1990).
    • (1990) Black's Law Dictionary , pp. 1251
  • 35
    • 17644439304 scopus 로고    scopus 로고
    • ACHE Preview: Strategizing Compliance
    • Feb. 16
    • See Kristen Hallam, ACHE Preview: Strategizing Compliance, MOD. HEALTHCARE, Feb. 16,1998, at 40, 20.
    • (1998) Mod. Healthcare , pp. 40
    • Hallam, K.1
  • 36
    • 0346492182 scopus 로고    scopus 로고
    • Pub. L. No. 93-406, 88 Stat. 829 (codified as amended in scattered sections of 26 U.S.C. and 29 U.S.C.)
    • See Employee Retirement Income Security Act of 1974, Pub. L. No. 93-406, 88 Stat. 829 (codified as amended in scattered sections of 26 U.S.C. and 29 U.S.C.); John T. Boese, When Angry Patients Become Angry Prosecutors: Medical Necessity Determinations, Quality of Care and the Qui Tam Law, 43 ST. LOUIS U.L.J. 53, 59-60 (1999).
    • Employee Retirement Income Security Act of 1974
  • 37
    • 85212249686 scopus 로고    scopus 로고
    • When Angry Patients Become Angry Prosecutors: Medical Necessity Determinations, Quality of Care and the Qui Tam Law
    • See Employee Retirement Income Security Act of 1974, Pub. L. No. 93-406, 88 Stat. 829 (codified as amended in scattered sections of 26 U.S.C. and 29 U.S.C.); John T. Boese, When Angry Patients Become Angry Prosecutors: Medical Necessity Determinations, Quality of Care and the Qui Tam Law, 43 ST. LOUIS U.L.J. 53, 59-60 (1999).
    • (1999) St. Louis U.L.J. , vol.43 , pp. 53
    • Boese, J.T.1
  • 38
    • 85212308760 scopus 로고    scopus 로고
    • last modified Feb. 22
    • As of July 1, 1998, the Medicare program began paying skilled nursing facilities on a prospective payment system, pursuant to section 4432(a) of the Balanced Budget Act of 1997. See Health Care Fin. Admin., SNF Prospective Payment System (last modified Feb. 22, 2000) 〈http://www. hcfa.gov/medicare/snfpps.htm〉. Capitated payments may make it more difficult for federal investigators to detect quality of care fraud, as there is less of a paper trail documenting services rendered, making reliance on qui tam insiders more important. See Laurie McGinley & David S. Cloud, U.S. Takes Aim at HMO Fraud in Medicare and Medicaid, WALL ST. J., Oct. 19, 1998, at A28.
    • (2000) SNF Prospective Payment System
  • 39
    • 85212290340 scopus 로고    scopus 로고
    • U.S. Takes Aim at HMO Fraud in Medicare and Medicaid
    • Oct. 19
    • As of July 1, 1998, the Medicare program began paying skilled nursing facilities on a prospective payment system, pursuant to section 4432(a) of the Balanced Budget Act of 1997. See Health Care Fin. Admin., SNF Prospective Payment System (last modified Feb. 22, 2000) 〈http://www. hcfa.gov/medicare/snfpps.htm〉. Capitated payments may make it more difficult for federal investigators to detect quality of care fraud, as there is less of a paper trail documenting services rendered, making reliance on qui tam insiders more important. See Laurie McGinley & David S. Cloud, U.S. Takes Aim at HMO Fraud in Medicare and Medicaid, WALL ST. J., Oct. 19, 1998, at A28.
    • (1998) Wall St. J.
    • McGinley, L.1    Cloud, D.S.2
  • 40
    • 85212304747 scopus 로고    scopus 로고
    • See 31 U.S.C.A. § 3729(a)
    • See 31 U.S.C.A. § 3729(a).
  • 41
    • 85212261750 scopus 로고    scopus 로고
    • See id. § 3729(a)(7)
    • See id. § 3729(a)(7).
  • 42
    • 85212287081 scopus 로고    scopus 로고
    • See id. § 3730(d)
    • See id. § 3730(d).
  • 43
    • 0032498680 scopus 로고    scopus 로고
    • G-Men Federal Resources are Stacking up to Tackle Healthcare Fraud
    • Mar. 9
    • See Deanna Bellandi & Kristen Hallam, G-Men Federal Resources are Stacking up to Tackle Healthcare Fraud, MOD. HEALTHCARE, Mar. 9, 1998, at 32, 33-34.
    • (1998) Mod. Healthcare , pp. 32
    • Bellandi, D.1    Hallam, K.2
  • 44
    • 85212258302 scopus 로고    scopus 로고
    • U.S. Dep't of Justice Health Care Fraud Rep.: Fiscal Year 1997
    • available in last modified Feb. 16, 2000
    • See U.S. DEP'T OF JUSTICE HEALTH CARE FRAUD REP.: FISCAL YEAR 1997 (1998), available in Health Care Fraud Report Fiscal Year 1997 (last modified Feb. 16, 2000) 〈http://www.usdoj.gov/dag/pubdoc/health97.htm 〉 [hereinafter 1997 FRAUD REPORT].
    • (1998) Health Care Fraud Report Fiscal Year 1997
  • 45
    • 85212282018 scopus 로고    scopus 로고
    • See Kikkawa, supra note 30, at 91; see also Paschke, supra note 20, at 173-74
    • See Kikkawa, supra note 30, at 91; see also Paschke, supra note 20, at 173-74.
  • 46
    • 0030630570 scopus 로고    scopus 로고
    • The Government's Use of the False Claims Act to Enforce Standards of Quality of Care: Ingenuity or the Heavy Hand of the 800-Pound Gorilla
    • See Michael M. Mustokoff et al., The Government's Use of the False Claims Act to Enforce Standards of Quality of Care: Ingenuity or the Heavy Hand of the 800-Pound Gorilla, 6 ANNALS HEALTH L. 137, 142-43 (1997).
    • (1997) Annals Health L. , vol.6 , pp. 137
    • Mustokoff, M.M.1
  • 47
    • 85212247604 scopus 로고    scopus 로고
    • See id. at 141, 143-44
    • See id. at 141, 143-44.
  • 48
    • 85212255614 scopus 로고    scopus 로고
    • See Kikkawa, supra note 30, at 122
    • See Kikkawa, supra note 30, at 122.
  • 49
    • 85212250266 scopus 로고    scopus 로고
    • See Paschke, supra note 20, at 165
    • See Paschke, supra note 20, at 165.
  • 50
    • 85212304857 scopus 로고    scopus 로고
    • See Hoffman, supra note 27, at 154
    • See Hoffman, supra note 27, at 154.
  • 51
    • 85212297944 scopus 로고    scopus 로고
    • note
    • No. 96-1271 (E.D. Pa. Feb. 21, 1996). David R. Hoffman, Assistant U.S. Attorney for theEastern District of Pennsylvania, was a prosecutor in the GMS Tucker case, and has written an articledescribing the case in detail. See generally Hoffman, supra note 27.
  • 52
    • 85212255610 scopus 로고    scopus 로고
    • See Hoffman, supra note 27, at 152-53
    • See Hoffman, supra note 27, at 152-53.
  • 53
    • 85212262055 scopus 로고    scopus 로고
    • See id.
    • See id.
  • 54
    • 85212261833 scopus 로고    scopus 로고
    • See id.
    • See id.
  • 55
    • 85212285506 scopus 로고    scopus 로고
    • See id. at 149-52 (citing 42 C.F.R. § 483.1-.75 (1996), and the Nursing Home Reform Act,42 U.S.C. § 1396r(b)(1995))
    • See id. at 149-52 (citing 42 C.F.R. § 483.1-.75 (1996), and the Nursing Home Reform Act,42 U.S.C. § 1396r(b)(1995)).
  • 56
    • 85212309859 scopus 로고    scopus 로고
    • See id.
    • See id.
  • 57
    • 85212258833 scopus 로고    scopus 로고
    • See id. at 154
    • See id. at 154.
  • 58
    • 85212286790 scopus 로고    scopus 로고
    • See id. at 155
    • See id. at 155.
  • 59
    • 0346390496 scopus 로고    scopus 로고
    • Behind the Veil Where the Action Is: Private Policy Making and American Health Care
    • See Eleanor D. Kinney, Behind the Veil Where the Action Is: Private Policy Making and American Health Care, 51 ADMIN. L. REV. 145, 166-67 (1999) (noting that the purpose and provisionsof Agency for Health Care Policy and Research (AHCPR) attach to the private development of clinicalguidelines and quality standards).
    • (1999) Admin. L. Rev. , vol.51 , pp. 145
    • Kinney, E.D.1
  • 60
    • 85212307430 scopus 로고    scopus 로고
    • Nursing Home Services Fraud: Hearing on Fraud and Abuse in Nursing Homes before the Subcomm. on Human Resources of the House Comm. on Gov't Reform and Oversight
    • Nursing Home Services Fraud: Hearing on Fraud and Abuse in Nursing Homes Before the Subcomm. on Human Resources of the House Comm. on Gov't Reform and Oversight, 105th Cong. 135,143 (1997) [hereinafter Nursing Home Hearing] (statement of Suzanne M. Weiss, Vice President and Counsel, Public Policy, American Association of Homes and Services for the Aging).
    • (1997) 105th Cong. , pp. 135143
  • 61
    • 85212280424 scopus 로고    scopus 로고
    • See id. at 141-44
    • See id. at 141-44.
  • 62
    • 85212277317 scopus 로고    scopus 로고
    • Pub. L. No. 100-203, 101 Stat. 1330 (codified as amended in scattered sections of 42 U.S.C.)
    • Pub. L. No. 100-203, 101 Stat. 1330 (codified as amended in scattered sections of 42 U.S.C.).
  • 63
    • 85212261613 scopus 로고    scopus 로고
    • supra note 56, (citing 42 C.F.R. § 483.25)
    • Nursing Home Hearing, supra note 56, at 141(citing 42 C.F.R. § 483.25).
    • Nursing Home Hearing , pp. 141
  • 64
    • 85212305695 scopus 로고    scopus 로고
    • See id. at 141-44
    • See id. at 141-44.
  • 65
    • 85212298047 scopus 로고    scopus 로고
    • See e.g., infra Part II.B.-E
    • See e.g., infra Part II.B.-E.
  • 66
    • 85212296924 scopus 로고    scopus 로고
    • No. 98-CV-139, 1998 U.S. Dist. LEXIS 4836 (E.D. Pa. Feb. 4, 1998)
    • No. 98-CV-139, 1998 U.S. Dist. LEXIS 4836 (E.D. Pa. Feb. 4, 1998).
  • 67
    • 85212282957 scopus 로고    scopus 로고
    • Nursing Homes Face More Quality-of-Care Suits: Nursing Home Recovery Act, FCA and State Laws Have Led to More Suits, Larger Damages
    • See Robert J. Milligan & Steven Wiggs, Nursing Homes Face More Quality-of-Care Suis: Nursing Home Recovery Act, FCA and State Laws Have Led to More Suits, Larger Damages, NA'L L.J., July 6, 1998, at B1 ting Complaint at 15, Chester Care Center (98-CV-139)).
    • (1998) Na'l L.J.
    • Milligan, R.J.1    Wiggs, S.2
  • 68
    • 85212296479 scopus 로고    scopus 로고
    • Chester Care Center, 1998 U.S. Dist. LEXIS 4836, at *2
    • Chester Care Center, 1998 U.S. Dist. LEXIS 4836, at *2.
  • 69
    • 85212299839 scopus 로고    scopus 로고
    • supra note 18
    • See 1998 FRAUD REPORT, supra note 18.
    • (1998) Fraud Report
  • 70
    • 85212279852 scopus 로고    scopus 로고
    • See id.
    • See id.
  • 71
    • 85212296811 scopus 로고    scopus 로고
    • See Chester Care Center, 1998 U.S. Dist. LEXIS 4836, at *3
    • See Chester Care Center, 1998 U.S. Dist. LEXIS 4836, at *3.
  • 72
    • 85212301675 scopus 로고    scopus 로고
    • note
    • See generally id. (setting forth the specific conditions of the settlement, implicating a number of outside sources of regulation including the AHCPR Guidelines, the Nursing Home Reform Act,Titles XVIII and XIX of the Social Security Act, the Americans with Disabilities Act of 1990, and sections 483.1 through 483.206 of 42 C.F.R.).
  • 73
    • 85212309037 scopus 로고    scopus 로고
    • note
    • See Milligan & Wiggs, supra note 63, at B13 (stating that "[f]rom a practical standpoint . . .government use of the FCA to supervise the quality of care will be a fact of life for long-term care providers and the attorneys who represent them.").
  • 74
    • 85212299839 scopus 로고    scopus 로고
    • supra note 18
    • See 1998 FRAUD REPORT, supra note 18.
    • (1998) Fraud Report
  • 75
    • 85212250099 scopus 로고    scopus 로고
    • last modified Oct. 28
    • Complaint ¶ 21, United States v. City of Philadelphia, 98-CV-4253 (E.D. Pa. Aug. 14, 199), available in U.S. Dep't of Justice Civil Rights Div., Special Litigation Section Home Page: Documets and Publications (last modified Oct. 28, 1999) 〈http://www.usdoj.gov/crt/split/documents/philcop.htm〉.
    • (1999) Special Litigation Section Home Page: Documets and Publications
  • 76
    • 85212280634 scopus 로고    scopus 로고
    • Id. ¶ 49
    • Id. ¶ 49.
  • 77
    • 85212250099 scopus 로고    scopus 로고
    • last modified Oct. 28
    • See Settlement Agreement, City of Philadelphia, 98-CV-4253, available in U.S. Dep't ofJustice Civil Rights Div., Special Litigation Section Home Page: Documents and Publications (last modified Oct. 28, 1999) 〈http://www.usdoj.gov/crt/split/documents/philsa.htm〉.
    • (1999) Special Litigation Section Home Page: Documents and Publications
  • 78
    • 85212263622 scopus 로고    scopus 로고
    • See Milligan & Wiggs, supra note 63, at B12; Hallam, supra note 33, at 40
    • See Milligan & Wiggs, supra note 63, at B12; Hallam, supra note 33, at 40.
  • 79
    • 85212276781 scopus 로고    scopus 로고
    • supra note 40
    • See Milligan & Wiggs, supra note 63, at B12. The United States Department of Justice stated one of its "Future Challenges" as follows: Although all significant health care fraud schemes warrant the Department's attention,we will be especially cognizant of the adverse impact of some providers' fraudulentactions on the health of the patients for whom they care. The denial of medicallynecessary services, threats to the health of the nation's elderly, and the underservice ofpopulations in managed care plans will receive the Department's special attention. 1997 FRAUD REPORT, supra note 40.
    • (1997) Fraud Report
  • 80
    • 85212259816 scopus 로고    scopus 로고
    • See Lynne A. Battaglia, Press Release from the U.S. Attorney's Office for the District of Md.,June 17, 1999, availab U.S. Attorney's Office for the District of Md., Press Releases 1999 (last modified Jan. 12, 2000) 〈http://www.usdoj.gov/usao/md/press99/nursinghome.htm〉.
    • Battaglia, L.A.1
  • 81
    • 85212307911 scopus 로고    scopus 로고
    • See Northern Health Facilities, Inc. v. United States, 39 F. Supp. 2d 563, 565 (D. Md. 1998)
    • See Northern Health Facilities, Inc. v. United States, 39 F. Supp. 2d 563, 565 (D. Md. 1998).
  • 82
    • 85212270334 scopus 로고    scopus 로고
    • See id. at 566
    • See id. at 566.
  • 83
    • 85212276763 scopus 로고    scopus 로고
    • See id.
    • See id.
  • 84
    • 85212300002 scopus 로고    scopus 로고
    • See id.
    • See id.
  • 85
    • 85212280702 scopus 로고    scopus 로고
    • See id.; Battaglia, supra note 76, at 1
    • See id.; Battaglia, supra note 76, at 1.
  • 86
    • 85212284254 scopus 로고    scopus 로고
    • Northern Health Facilities
    • See Northern Health Facilities, 39 F. Supp. 2d at 566; Battaglia, supra note 76, at 1.
    • F. Supp. 2d , vol.39 , pp. 566
  • 87
    • 85212307687 scopus 로고    scopus 로고
    • Battaglia, supra note 76, at 1
    • See Northern Health Facilities, 39 F. Supp. 2d at 566; Battaglia, supra note 76, at 1.
  • 88
    • 85212284254 scopus 로고    scopus 로고
    • Northern Health Facilities
    • See Northern Health Facilities, 39 F. Supp. 2d at 566-67.
    • F. Supp. 2d , vol.39 , pp. 566-567
  • 89
    • 85212263006 scopus 로고    scopus 로고
    • See id.
    • See id.
  • 90
    • 85212308245 scopus 로고    scopus 로고
    • Id. at 567 (citing Consent Order at 19, United States v. Northern Health Facilities, Inc., No.CIV.A. AW 98-3113 (D. Md. Sept. 15, 1998))
    • Id. at 567 (citing Consent Order at 19, United States v. Northern Health Facilities, Inc., No.CIV.A. AW 98-3113 (D. Md. Sept. 15, 1998)).
  • 91
    • 85212271542 scopus 로고    scopus 로고
    • Id. (citing Consent Order at 20, United States v. Northern Health Facilities, Inc., No. CIV.A.AW 98-3113)
    • Id. (citing Consent Order at 20, United States v. Northern Health Facilities, Inc., No. CIV.A.AW 98-3113).
  • 92
    • 85212285619 scopus 로고    scopus 로고
    • note
    • See Aussprung, supra note 18, at 3; see also Krohn, supra note 28, at 461-62 (noting that theFCA implicitly encourages settlement and that settlements are often negotiated to include a denial ofguilt and a secrecy clause because of provider concern over negative public opinion).
  • 93
    • 85212291245 scopus 로고    scopus 로고
    • See United States ex rel. Aranda v. Community Psychiatric Ctrs., 945 F. Supp. 1485, 1489 (W.D. Okla. 1996); Huffman, supra note 27, at 155-56
    • See United States ex rel. Aranda v. Community Psychiatric Ctrs., 945 F. Supp. 1485, 1489 (W.D. Okla. 1996); Huffman, supra note 27, at 155-56.
  • 94
    • 85212254636 scopus 로고    scopus 로고
    • Aranda
    • See Aranda, 945 F. Supp. at 1489.
    • F. Supp. , vol.945 , pp. 1489
  • 95
    • 85212257443 scopus 로고    scopus 로고
    • See id. at 1488
    • See id. at 1488.
  • 96
    • 85212261664 scopus 로고    scopus 로고
    • See id.
    • See id.
  • 97
    • 85212295767 scopus 로고    scopus 로고
    • See id. at 1488-89
    • See id. at 1488-89.
  • 98
    • 85212288370 scopus 로고    scopus 로고
    • See id. at 1487-88
    • See id. at 1487-88.
  • 99
    • 85212260641 scopus 로고    scopus 로고
    • Id. at 1488 (citing 42 U.S.C. § 1320c-5)
    • Id. at 1488 (citing 42 U.S.C. § 1320c-5).
  • 100
    • 85212281984 scopus 로고    scopus 로고
    • note
    • See id. Other standards cited by the court were the Medicare Fraud and Abuse Statute,42 U.S.C. § 1320a-7(b)(6)(B) (allowing program exclusion for anyone furnishing patient services "o a quality which fails to meet professionally recognized standards of health care"), 42 U.S.C. § 96a(a)(30)(A) (requiring a state plan for medical assistance to specify payment for serviceprocedures sufficient "to assure that payments are consistent with . . . quality of care") and 42 C.F.R. §455.2 (defining "abuse" for the purpose of Medicaid exclusion as "provider practices that areinconsistent with sound . . . medical practices, and result in an unnecessary cost to the Medicaidprogram, or in reimbursement for services . . . that fail to meet professionally recognized standards forhealth care").
  • 101
    • 85212293624 scopus 로고    scopus 로고
    • Aranda
    • See Aranda, 945 F. Supp. at 1488. See generally David C. Hsia, Application of Qui Tam to the Quality of Health Care, 14 J. LEGAL MED. 301 (1993) (discussing the complexity of quality measurement in FCA qui tam actions).
    • F. Supp. , vol.945 , pp. 1488
  • 102
    • 0027281196 scopus 로고
    • Application of Qui Tam to the Quality of Health Care
    • See Aranda, 945 F. Supp. at 1488. See generally David C. Hsia, Application of Qui Tam to the Quality of Health Care, 14 J. LEGAL MED. 301 (1993) (discussing the complexity of quality measurement in FCA qui tam actions).
    • (1993) J. Legal Med. , vol.14 , pp. 301
    • Hsia, D.C.1
  • 103
    • 85212260991 scopus 로고    scopus 로고
    • Aranda
    • See Aranda, 945 F. Supp. at 1499.
    • F. Supp. , vol.945 , pp. 1499
  • 104
    • 85212259034 scopus 로고    scopus 로고
    • See id.
    • See id.
  • 105
    • 85212276781 scopus 로고    scopus 로고
    • supra note 40
    • See 1997 FRAUD REPORT, supra note 40.
    • (1997) Fraud Report
  • 106
    • 85212295701 scopus 로고    scopus 로고
    • See supra Part III
    • See supra Part III.
  • 107
    • 85212282465 scopus 로고    scopus 로고
    • note
    • While several health maintenance organizations (HMOs) have already been prosecuted underth for other fraud and abuse issues, see McGinley & Cloud, supra note 35, at A28, none have apparently yet been liable under a quality of care theory.
  • 108
    • 85212299811 scopus 로고    scopus 로고
    • Pub. L. No. 105-33 sec. 4701, § 1932, 111 Stat. 251, 489-93 (codified as amended inscattered sections of 42 U.S.C.)
    • Pub. L. No. 105-33 sec. 4701, § 1932, 111 Stat. 251, 489-93 (codified as amended inscattered sections of 42 U.S.C.).
  • 109
    • 85031757803 scopus 로고    scopus 로고
    • Establishment of the Medicare+Choice Program
    • Coordinated care plans include HMOs, Preferred Provider Organizations, and Provider-Sponsored Organizations. See Medicare Program; Establishment of the Medicare+Choice Program, 63 Fed. Reg. 34,968, 34,968-69 (1998) (codified at 42 C.F.R. pts. 400, 403, 410, 411, 417 & 422).
    • (1998) Fed. Reg. , vol.63 , pp. 34968
  • 111
    • 85212307666 scopus 로고    scopus 로고
    • See Krohn, supra note 28, at 465-66; McGinley & Cloud, supra note 35, at A28
    • See Krohn, supra note 28, at 465-66; McGinley & Cloud, supra note 35, at A28.
  • 112
    • 85212304983 scopus 로고    scopus 로고
    • Establishment of the Medicare+Choice Program
    • See Medicare Program; Establishment of the Medicare+Choice Program, 63 Fed. Reg. at34,969.
    • Fed. Reg. , vol.63 , pp. 34969
  • 113
    • 85212266585 scopus 로고    scopus 로고
    • 42 C.F.R. § 422.502(a)(3)(iii) (1999)
    • 42 C.F.R. § 422.502(a)(3)(iii) (1999).
  • 114
    • 85212300351 scopus 로고    scopus 로고
    • note
    • A Medicare+Choice (M+C) organization is "a public or private entity organized and licensedby a State as a risk-bearing entity (with the exception of provider-sponsored organizations receivingwaivers) that is certified by HCFA as meeting the M+C contracting requirements." 42 C.F.R. § 422.2 (1999). An M+C plan refers to "health benefits coverage offered under a policy or contract by an M+Corganization that includes a specific set of health benefits offered at a uniform premium and uniformlevel of cost-sharing to all Medicare beneficiaries residing in the service of the M+C plan." Id.
  • 115
    • 85212279603 scopus 로고    scopus 로고
    • HCFA Will Assess Plans' History before Medicare+Choice OK Given
    • June 19, available in 1998 WL 9851466
    • See HCFA Will Assess Plans' History Before Medicare+Choice OK Given, PHYSICIAN MANAGER, June 19, 1998, at 3, 3, available in 1998 WL 9851466.
    • (1998) Physician Manager , pp. 3
  • 116
    • 85212302453 scopus 로고    scopus 로고
    • See discussion supra Parts III.A.-E
    • See discussion supra Parts III.A.-E.
  • 117
    • 85212283725 scopus 로고    scopus 로고
    • note
    • See Boese, supra note 34, at 69; McGinley & Cloud, supra note 35, at A28 (quoting James Sheehan, Assistant U.S. Attorney in Philadelphia, as stating: "When you pay organizations the same amount of money whether or not they provide medically necessary services, there is always the temptation for fraud.").
  • 118
    • 85212296167 scopus 로고    scopus 로고
    • See United States v. Krizek, 111 F.3d 934, 939 (D.C. Cir. 1997)
    • See United States v. Krizek, 111 F.3d 934, 939 (D.C. Cir. 1997).
  • 119
    • 85212279867 scopus 로고    scopus 로고
    • note
    • Form HCFA-1500 is used by non-institutional providers for fee-for-service reimbursementunder Medicare Part B. Health Care Fin. Admin., Health Insurance Claim Form, Form HCFA-1500 (12-90), Form RRB-1500, Form OWCP-1500.
  • 120
    • 85212283812 scopus 로고    scopus 로고
    • Krizek
    • See Krizek, 111 F.3d at 939-40.
    • F.3d , vol.111 , pp. 939-940
  • 121
    • 85212278723 scopus 로고    scopus 로고
    • Id. at 939
    • Id. at 939.
  • 122
    • 85212261365 scopus 로고    scopus 로고
    • note
    • See id. at 939-40 (stating that "The question turns, not on how the government chooses toprocess the claim, but on how many times the defendants made a 'request or demand.'").
  • 123
    • 85212247750 scopus 로고    scopus 로고
    • _ F. Supp. 2d _ , No. 92 CiV. 2754(CM), 1999 WL 1066863 (S.D.N.Y. Nov. 18, 1999)
    • _ F. Supp. 2d _ , No. 92 CiV. 2754(CM), 1999 WL 1066863 (S.D.N.Y. Nov. 18, 1999).
  • 124
    • 85212267917 scopus 로고    scopus 로고
    • Id. at *7
    • Id. at *7.
  • 125
    • 85212251580 scopus 로고    scopus 로고
    • See id. at *7-*9
    • See id. at *7-*9.
  • 127
    • 85212292092 scopus 로고    scopus 로고
    • See id.
    • See id.
  • 128
    • 85212288707 scopus 로고    scopus 로고
    • Nat'l Unif. Billing Comm., UB-92 HCFA-1450; Form HCFA-1500, supra note 112
    • Nat'l Unif. Billing Comm., UB-92 HCFA-1450; Form HCFA-1500, supra note 112.
  • 129
    • 85212288518 scopus 로고    scopus 로고
    • 914 F. Supp. 1507 (M.D. Tenn. 1996)
    • 914 F. Supp. 1507 (M.D. Tenn. 1996).
  • 130
    • 85212306764 scopus 로고    scopus 로고
    • See Pogue, 914 F. Supp. at 1509-10
    • See Pogue, 914 F. Supp. at 1509-10.
  • 131
    • 85212262003 scopus 로고    scopus 로고
    • See id
    • See id.
  • 132
    • 85212263776 scopus 로고    scopus 로고
    • Id. at 1511
    • Id. at 1511.
  • 133
    • 85212272825 scopus 로고    scopus 로고
    • 125 F.3d 899 (5th Cir. 1997)
    • 125 F.3d 899 (5th Cir. 1997).
  • 134
    • 85212289986 scopus 로고    scopus 로고
    • See id. at 902-03
    • See id. at 902-03.
  • 135
    • 85212307439 scopus 로고    scopus 로고
    • See id.
    • See id.
  • 136
    • 85212262929 scopus 로고    scopus 로고
    • See United States ex rel. Thomson v. Columbia/HCA Healthcare Corp., 20 F. Supp. 2d 107, 1046-48 (S.D. Tex. 1998)
    • See United States ex rel. Thomson v. Columbia/HCA Healthcare Corp., 20 F. Supp. 2d 107, 1046-48 (S.D. Tex. 1998).
  • 137
    • 85212291499 scopus 로고    scopus 로고
    • Id. at 1042
    • Id. at 1042.
  • 138
    • 85212290043 scopus 로고    scopus 로고
    • note
    • See Thomson, 125 F.3d at 903; United States ex rel. Mikes v. Straus, _ F. Supp. 2d _, No. 92 CIV. 2754(CM), 1999 WL 1066863, at *7-*9 (S.D.N.Y. Nov. 18, 1999). For a more complte analysis of the ant kback cases, see generally Kikkawa, supra note 30.
  • 139
    • 85212274150 scopus 로고    scopus 로고
    • 67 F. Supp. 2d 637 (S.D. Miss. 1999)
    • 67 F. Supp. 2d 637 (S.D. Miss. 1999).
  • 140
    • 85212279911 scopus 로고    scopus 로고
    • See id. at 637
    • See id. at 637.
  • 141
    • 85212296885 scopus 로고    scopus 로고
    • See id. at 640
    • See id. at 640.
  • 142
    • 85212269436 scopus 로고    scopus 로고
    • See id.
    • See id.
  • 143
    • 85212274913 scopus 로고    scopus 로고
    • Id. at 641
    • Id. at 641.
  • 144
    • 85212256176 scopus 로고    scopus 로고
    • See id. at 642
    • See id. at 642.
  • 145
    • 85212290728 scopus 로고    scopus 로고
    • See id.
    • See id.
  • 146
    • 85212279816 scopus 로고    scopus 로고
    • See id.
    • See id.
  • 147
    • 85212285504 scopus 로고    scopus 로고
    • See id.
    • See id.
  • 148
    • 85212256593 scopus 로고    scopus 로고
    • See id. at 645
    • See id. at 645.
  • 149
    • 85212261471 scopus 로고    scopus 로고
    • See discussion supra Part I
    • See discussion supra Part I.
  • 150
    • 85212268685 scopus 로고    scopus 로고
    • See Intervest Corp., 67 F. Supp. 2d at 647
    • See Intervest Corp., 67 F. Supp. 2d at 647.
  • 151
    • 85212250854 scopus 로고    scopus 로고
    • 176 F.3d 776, 785 (4th Cir. 1999)
    • 176 F.3d 776, 785 (4th Cir. 1999).
  • 152
    • 85212290009 scopus 로고    scopus 로고
    • Intervest Corp., 67 F. Supp. 2d at 646
    • Intervest Corp., 67 F. Supp. 2d at 646.
  • 153
    • 85212250535 scopus 로고    scopus 로고
    • See id. at 647
    • See id. at 647.
  • 154
    • 85212271953 scopus 로고    scopus 로고
    • See id. at 647-48
    • See id. at 647-48.
  • 155
    • 85212254244 scopus 로고    scopus 로고
    • See id. at 648
    • See id. at 648.
  • 156
    • 85212297430 scopus 로고    scopus 로고
    • See id.
    • See id.
  • 157
    • 85212259481 scopus 로고    scopus 로고
    • See supra Part III.D
    • See supra Part III.D.
  • 158
    • 85212262930 scopus 로고    scopus 로고
    • See Northern Health Facilities, Inc. v. United States, 39 F. Supp. 2d 563, 565-66 (. Md. 1998)
    • See Northern Health Facilities, Inc. v. United States, 39 F. Supp. 2d 563, 565-66 (. Md. 1998).
  • 159
    • 85212275280 scopus 로고    scopus 로고
    • Id. at 566
    • Id. at 566.
  • 160
    • 85212294260 scopus 로고    scopus 로고
    • Presumably, state regulator complacency might also foil an FCA challenge in the case of fraudulent Medicaid certifications
    • Presumably, state regulator complacency might also foil an FCA challenge in the case of fraudulent Medicaid certifications.
  • 161
    • 85212267840 scopus 로고    scopus 로고
    • Fraud and Abuse: PA Facility to Pay $195,000 to Settle Quality of Care False Claims Issues
    • May 21
    • See, e.g., Fraud and Abuse: PA Facility to Pay $195,000 to Settle Quality of Care False Claims Issues, 4 Health Care Daily Rep. (BNA) 3, 3-4 (May 21, 1999) (discussing the 1999 settlemnt of Integrated Health Services (IHS) at Penn Inc., a for-profit company operating IHS of Bryn Mawrat the Chateau, a skilled nursing facility in Bryn Mawr, Pennsylvania, accused of poor quality of car). The IHS allegations were similar to those of the other nursing home quality of care cases, alleging tat residents suffered from incontinence and bed sores. See id. HCFA fined IHS for similar violationsin 1996, but IHS had maintained a clean record since then. See id.
    • (1999) Health Care Daily Rep. (BNA) , vol.4 , pp. 3
  • 162
    • 85212257062 scopus 로고    scopus 로고
    • § .2, cmt. 3(k) (Nov. 198)
    • See U.S. SENTENCING COMM., GUIDELINES MANUAL, § .2, cmt. 3(k) (Nov. 198) (defining "effective program to prevent and detect violations of law").
    • Sentencing Comm., Guidelines Manual
  • 163
    • 85212256966 scopus 로고    scopus 로고
    • See id. § 8C2.5
    • See id. § 8C2.5.
  • 164
    • 85212282134 scopus 로고    scopus 로고
    • Aussprung, supra note 18, at 50-51
    • Aussprung, supra note 18, at 50-51.
  • 165
    • 0031550683 scopus 로고    scopus 로고
    • Publication of the OIG Compliance Program Guidance for Clinical Laboratories
    • Publication of the OIG Compliance Program Guidance for Clinical Laboratories, 62 Fed. Reg. 9,435 (1997).
    • (1997) Fed. Reg. , vol.62 , pp. 9435
  • 166
    • 85212271052 scopus 로고    scopus 로고
    • See id.
    • See id.
  • 167
    • 0032559529 scopus 로고    scopus 로고
    • Publication of the OIG Compliance Program Guidance for Hospitals
    • Publication of the OIG Compliance Program Guidance for Hospitals, 63 Fed. Reg. 8,987 (1998).
    • (1998) Fed. Reg. , vol.63 , pp. 8987
  • 168
    • 0032493519 scopus 로고    scopus 로고
    • Publication of the OIG Compliance Program Guidance for Home Health Agencies
    • Publication of the OIG Compliance Program Guidance for Home Health Agencies, 63 Fed.Reg. 42,410 (1998).
    • (1998) Fed. Reg. , vol.63 , pp. 42410
  • 169
    • 0343446017 scopus 로고    scopus 로고
    • Publication of the OIG Compliance Program Guidance for Third-party Medical Billing Companies
    • Publication of the OIG Compliance Program Guidance for Third-Party Medical Billing Companies, 63 Fed. Reg. 70,138 (1998).
    • (1998) Fed. Reg. , vol.63 , pp. 70138
  • 170
    • 0342904016 scopus 로고    scopus 로고
    • Publication of the OIG Compliance Program Guidance for the Durable Medical Equipment, Prosthetics, Orthotics and Supply Industry
    • Publication of the OIG Compliance Program Guidance for the Durable Medical Equipment, Prosthetics, Orthotics and Supply Industry, 64 Fed. Reg. 36,368 (1999).
    • (1999) Fed. Reg. , vol.64 , pp. 36368
  • 171
    • 0342469589 scopus 로고    scopus 로고
    • Publication of the OIG Compliance Program Guidance for Hospices
    • Publication of the OIG Compliance Program Guidance for Hospices, 64 Fed. Reg. 54,031 (1999).
    • (1999) Fed. Reg. , vol.64 , pp. 54031
  • 172
    • 0343774805 scopus 로고    scopus 로고
    • Publication of the OIG's Compliance Program Guidance for Medicare+Choice Organizations Offering Coordinated Care Plans
    • Publication of the OIG's Compliance Program Guidance for Medicare+Choice Organizations Offering Coordinated Care Plans, 64 Fed. Reg. 61,893 (1999).
    • (1999) Fed. Reg. , vol.64 , pp. 61893
  • 173
    • 0032563433 scopus 로고    scopus 로고
    • Publication of the OIG Compliance Program Guidance for Clinical Laboratories
    • Publication of the OIG Compliance Program Guidance for Clinical Laboratories, 63 Fed. Reg. 45,076 (1998).
    • (1998) Fed. Reg. , vol.63 , pp. 45076
  • 174
    • 85212256170 scopus 로고    scopus 로고
    • Draft OIG Compliance Program Guidance for Nursing Facilities
    • Draft OIG Compliance Program Guidance for Nursing Facilities, 64 Fed. Reg. 58,419 (1999).
    • (1999) Fed. Reg. , vol.64 , pp. 58419
  • 175
    • 85212253636 scopus 로고    scopus 로고
    • Solicitation of Information and Recommendations for Developing OIG Compliance Program Guidance for Individual icians and Small Group Practices
    • Solicitation of Information and Recommendations for Developing OIG Compliance Program Guidance for Individual icians and Small Group Practices, 64 Fed. Reg. 48,846 (1999).
    • (1999) Fed. Reg. , vol.64 , pp. 48846
  • 176
    • 0343774805 scopus 로고    scopus 로고
    • Publication of the OIG's Compliance Program Guidance for Medicare+Choice Organizations Offering Coordinated Care Plans
    • Publication of the OIG's Compliance Program Guidance for Medicare+Choice Organizations Offering Coordinated Care Plans, 64 Fed. Reg. at 61,893.
    • Fed. Reg. , vol.64 , pp. 61893
  • 177
    • 85212277430 scopus 로고    scopus 로고
    • note
    • See id. at 61,897. The other identified risk areas are: marketing materials and personnel,selective marketing and enrollment, disenrollment, data collection and submission processes, anti-kickback statute and other inducements, and emergency services. See id.
  • 178
    • 85212257927 scopus 로고    scopus 로고
    • Id. at 61,899
    • Id. at 61,899.
  • 179
    • 85212250233 scopus 로고    scopus 로고
    • See id. at 61,907
    • See id. at 61,907.
  • 180
    • 85212272655 scopus 로고    scopus 로고
    • See id.
    • See id.
  • 181
    • 85212303654 scopus 로고    scopus 로고
    • See Holder Memorandum, supra note 21
    • See Holder Memorandum, supra note 21.
  • 182
    • 85212277285 scopus 로고    scopus 로고
    • Id.
    • Id.
  • 183
    • 85212282103 scopus 로고    scopus 로고
    • Remarks to the American Hospital Association (Feb. 1, 1999), available in U.S. Department of Justice, last modified Feb. 08
    • Deputy Attorney General Eric H. Holder, Jr., Remarks to the American Hospital Association (Feb. 1, 1999), available in U.S. Department of Justice, Deputy Attorney General Speech (last modified Feb. 08, 1999) 〈http://www.usdoj.gov/dag/speech/holderahaspeech.htm〉.
    • (1999) Deputy Attorney General Speech
    • Holder E.H., Jr.1
  • 184
    • 85212276823 scopus 로고    scopus 로고
    • See Holder Memorandum, supra note 21
    • See Holder Memorandum, supra note 21.
  • 185
    • 85212306028 scopus 로고    scopus 로고
    • Id.
    • Id.
  • 186
    • 85212305316 scopus 로고    scopus 로고
    • last modified Jan. 18
    • See Memorandum from June Gibbs Brown, Department of Health and Human Services Inspector General, to the Deputy Inspector General for Investigations, the Deputy Inspector General for Audit Services, and the Assistant Inspector General for Legal Affairs (June 3, 1998) [hereinafter Brown Memorandum]. The Holder and Brown memoranda were initially circulated in response to the Health Care Claims Guidance Act (HCCGA) introduced in both houses during the second session of the 105th Congress. See S. 2007, 105th Cong. (1998); H.R. 3523, 105th Cong. (1998). The HCCGA uld have severely limited recovery for health care fraud under the FCA. See id. At the end of the 105th term, both bills had been referred to subcommittees where they subsequently died. See Bill Summary & Status for the 105th Congress (last modified Jan. 18, 2000) 〈http://thomas.loc.gov/bss/d105query.html〉. The HCCGA included proposals to limit recovery under the FCA with respect to federally funded health care programs. See S. 2007; H.R. 3523. The hearingsin the House Subcommittee on Immigration and Claims elicited significant debate over the need for astrong FCA with which to fight health care fraud. See generally Oversight Hearing on Health Care Initiatives Under the False Claims Act that Impact Hospitals: Hearings on H.R. 3523 Before the Subcomm. on Immigration and Claims of the House Judiciary Comm., 105th Cong. (1998) [her ter Hearings] (documenting the statements of several health industry and DOJ speakers on the prudence of amending the FCA to weaken it as applied to health care). The HCCGA would have limited the FCA to circumstances where alleged damages were of a "material amount." See S. 2007; H.R. 3523. Moreover, the HCCGA would have denied recovery if a defendant relied on "written statements of Federal policy" or if an action sought to recover for "claims submitted by persons in substantial compliance with a model compliance plan." S. 2007; H.R. 3523. Finally, the HCCGA would have raised the standard of proof required in an FCA health care claim to "clear and convincing evidence." S. 2007; H.R. 3523. During hearings before the House Judiciary Committee Subcommittee on Immigration and Claims, one speaker suggested that the HCCGA would make relators less likely tobring suits for quality of care problems, as the quality of care rendered to one health care consumermay well not amount to a "material amount" required to bring suit. See Hearings (testimony of Lewis Morris, Assistant Inspector General for Legal Affairs, HHS) (arguing that the materiality requirementwould effectively result in "free for fraud zones"). The practical effect of the guidance set forth in the Holder and Brown memoranda was to appease the HCCGA's proponents and put that bill to rest.
    • (2000) Bill Summary & Status for the 105th Congress
  • 187
    • 85212276092 scopus 로고    scopus 로고
    • Oversight Hearing on Health Care Initiatives under the False Claims Act that Impact Hospitals: Hearings on H.R. 3523 before the Subcomm. on Immigration and Claims of the House Judiciary Comm
    • See Memorandum from June Gibbs Brown, Department of Health and Human Services Inspector General, to the Deputy Inspector General for Investigations, the Deputy Inspector General for Audit Services, and the Assistant Inspector General for Legal Affairs (June 3, 1998) [hereinafter Brown Memorandum]. The Holder and Brown memoranda were initially circulated in response to the Health Care Claims Guidance Act (HCCGA) introduced in both houses during the second session of the 105th Congress. See S. 2007, 105th Cong. (1998); H.R. 3523, 105th Cong. (1998). The HCCGA uld have severely limited recovery for health care fraud under the FCA. See id. At the end of the 105th term, both bills had been referred to subcommittees where they subsequently died. See Bill Summary & Status for the 105th Congress (last modified Jan. 18, 2000) 〈http://thomas.loc.gov/bss/d105query.html〉. The HCCGA included proposals to limit recovery under the FCA with respect to federally funded health care programs. See S. 2007; H.R. 3523. The hearingsin the House Subcommittee on Immigration and Claims elicited significant debate over the need for astrong FCA with which to fight health care fraud. See generally Oversight Hearing on Health Care Initiatives Under the False Claims Act that Impact Hospitals: Hearings on H.R. 3523 Before the Subcomm. on Immigration and Claims of the House Judiciary Comm., 105th Cong. (1998) [her ter Hearings] (documenting the statements of several health industry and DOJ speakers on the prudence of amending the FCA to weaken it as applied to health care). The HCCGA would have limited the FCA to circumstances where alleged damages were of a "material amount." See S. 2007; H.R. 3523. Moreover, the HCCGA would have denied recovery if a defendant relied on "written statements of Federal policy" or if an action sought to recover for "claims submitted by persons in substantial compliance with a model compliance plan." S. 2007; H.R. 3523. Finally, the HCCGA would have raised the standard of proof required in an FCA health care claim to "clear and convincing evidence." S. 2007; H.R. 3523. During hearings before the House Judiciary Committee Subcommittee on Immigration and Claims, one speaker suggested that the HCCGA would make relators less likely tobring suits for quality of care problems, as the quality of care rendered to one health care consumermay well not amount to a "material amount" required to bring suit. See Hearings (testimony of Lewis Morris, Assistant Inspector General for Legal Affairs, HHS) (arguing that the materiality requirementwould effectively result in "free for fraud zones"). The practical effect of the guidance set forth in the Holder and Brown memoranda was to appease the HCCGA's proponents and put that bill to rest.
    • (1998) 105th Cong.
  • 188
    • 85212287680 scopus 로고    scopus 로고
    • See Brown Memorandum, supra note 180, at 46
    • See Brown Memorandum, supra note 180, at 46.
  • 189
    • 85212294856 scopus 로고    scopus 로고
    • Id.
    • Id.
  • 190
    • 85212277931 scopus 로고    scopus 로고
    • Id. at 47
    • Id. at 47.
  • 191
    • 85212303951 scopus 로고    scopus 로고
    • See Kikkawa, supra note 30, at 122
    • See Kikkawa, supra note 30, at 122.
  • 192
    • 85212303592 scopus 로고    scopus 로고
    • See 31 U.S.C.A. § 3730(e)(3) (West 1999)
    • See 31 U.S.C.A. § 3730(e)(3) (West 1999).
  • 193
    • 85212298989 scopus 로고    scopus 로고
    • See id. § 3730(e)(4)
    • See id. § 3730(e)(4).
  • 194
    • 85212288283 scopus 로고    scopus 로고
    • note
    • See Holder Memorandum, supra note 21 (citing factors to consider in determining whether a false claim was knowingly submitted, including: "a. Notice to the Provider . . . b. The Clarity of the Rule or Policy . . . c. The Pervasiveness and Magnitude of the False Claims . . . d. Compliance Plansand Other Steps to Comply with Billing Rates . . . e. Past Remedial Efforts . . . f. Guidance by the Program Agency or its Agents"); Brown Memorandum, supra note 180, at 47 (stating "[t]he OIG supports the equitable treatment of providers in national projects. . . . [C]ompliance or corporateintegrity provisions should be uniform and consistently applied.").


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