Supreme Court won't hear case challenging physician's opinion under False Claims Act

The Supreme Court declined to review a case alleging healthcare management company RollinsNelson violated the False Claims Act by submitting claims for medically unnecessary hospital admissions, according to Bloomberg Law.

The case's key question was whether a Medicare reimbursement claim for inpatient hospital care could be "false" under the False Claims Act based on an after-the-fact review of medical records that disagrees with the admitting physician’s medical opinion. 

In its petition to the Supreme Court, RollinsNelson argued that the U.S. Court of Appeals for the 9th Circuit wrongly rejected the objective falsehood requirement of the False Claims Act and wrongly viewed whether a difference of opinion over medical judgements is actionable. 

The 9th Circuit on March 23, 2020, ruled that whistleblower Jane Winter, RN, a former hospital director in California, could proceed with her claims. The panel reversed a lower court's dismissal of the claim.

Ms. Winter's job at Gardens Regional Hospital and Medical Center in California was reviewing patients' medical records and applying admission criteria to evaluate the medical necessity of admissions. RollinsNelson, which owns several nursing homes, acquired a 50 percent ownership interest in S&W, the management company overseeing Gardens Regional, in 2014 and began jointly managing the hospital. 

Ms. Winter alleges she saw an uptick in nursing home patients being admitted to Gardens Regional for inpatient treatment after the acquisition. Specifically, Ms. Winter detailed 65 instances where patients hospitalized didn't meet Gardens Regional's admission criteria or medical necessity wasn't made clear in their medical records. 

Ms. Winter alleges that RollinsNelson and S&W "exerted direct pressure on physicians to admit patients to [Gardens Regional] and cause false claims to be submitted based on false certifications of medical necessity."

A lower court had dismissed Ms. Winter's claims, stating that a determination of medical necessity is a subjective opinion that can’t be medically false.

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