FCA Risk in Medicare Advantage Continues to Grow: Derrick v. Hoffman-La Roche

• March 17, 2021

• Steven D. Hamilton , Reed Smith LLP
• Jarrad Wood , Reed Smith LLP

By this point, most health care fraud and abuse lawyers are familiar with the federal False Claims Act (FCA) cases and issues relating to risk adjustment payments to Medicare Advantage Organizations (MAOs). While those cases continue, risk adjustment is not the only area of FCA risk to MAOs and other government-sponsored health plans. One such area is the federal Anti-Kickback Statute (AKS), which prohibits offering, paying, soliciting, or receiving any remuneration to induce or reward referrals or generate federal health care program business. While AKS issues historically have cropped up with respect to health care providers, remuneration includes any payment or other benefit made directly or indirectly, overtly or covertly, in cash or in kind, for referrals or arranging for the provision of health care services, subject to specific exclusions. This is problematic because of the nature of government sponsored health plans’ business of contracting with providers and other vendors to perform most services—all of which is paid with federal program dollars.

ARTICLE TAGS

• Health Care Liability and Litigation Practice Group
• Fraud and Compliance
• Government Reimbursement