On September 9, 2019, the Eleventh Circuit issued a highly anticipated opinion addressing the question of when Medicare claims for reimbursement (in this case, claims for hospice care) can be considered “false” under the federal False Claims Act (FCA). Importantly, the decision could be viewed as a victory for health care providers because it established limitations on the government’s ability to argue that a Medicare claim is false based on the allegedly flawed clinical judgment of the physician responsible for providing or certifying the necessity of the care billed to the government. The case involves allegations that the defendants falsely certified patients as eligible for hospice care based on erroneous clinical determinations by physicians that the patients were terminally ill. Significantly, the court held that when a physician’s clinical judgment required for billing purposes is at issue, “the claim cannot be ‘false’—and thus cannot trigger FCA liability—if the underlying clinical judgment does not reflect an objective falsehood.”

The full opinion in United States v. AseraCare, Inc., No. 16-13004, 2019 WL 4251875 (11th Cir. Sept. 9, 2019), can be found here.