RollinsNelson LTC Corp., et al. v. United States, ex rel. Jane Winters

This case turns on whether a Medicare reimbursement claim for inpatient hospital care can be alleged “false” under the False Claims Act (“FCA”) based solely on a post hoc review of medical records that disagrees with the admitting physician’s medical opinion. At issue here are the clinical judgments of several physicians, each expressing the view that inpatient hospital care was reasonable and necessary for a particular Medicare beneficiary. Medicare’s regulations directed those physicians to apply indeterminate and purposefully vague standards governing whether care was reimbursable. Indeterminate standards give providers the flexibility they need to supply covered healthcare to beneficiaries who present with an infinite array of ailments. By their nature, though, indeterminate standards are also subject to differing opinions and medical judgments, which are impossible in most circumstances to prove objectively false. Unfortunately, the lower courts have become irreconcilably split as to whether the FCA’s falsity element requires an objective falsehood, and therefore whether a difference of opinion over medical judgments is actionable. The decision below wrongly rejected the objective falsehood requirement, deepening and worsening the split. Healthcare professionals and Medicare providers deserve a unified national standard for falsity under the FCA. Thus, the question presented is: Whether the False Claims Act requires pleading and proof of an objectively false statement.