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Management pressured staff to inflate Medicare reimbursements by “upcoding” and “ramping.”

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The Seventh Circuit Court of Appeals has held that arrangements with a third-party litigation funder did not deprive a whistleblower of legal “standing” to pursue her claims under the False Claims Act.  It also upheld a $255 million jury verdict for Medicare fraud against the two Florida skilled nursing facilities where the whistleblower worked and the management firms that ran them.

The court’s decision in Ruckh v. Salus Rehabilitation counts as a significant victory for whistleblowers.  Healthcare industry defense lawyers are fretting about its potential consequences.

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Former employee blows the whistle, receives reward

In another False Claims Act settlement involving trade fraud, the owner of New York jewelry wholesaler Anaya Gems Inc. has agreed to pay $415,000 to resolve allegations relating to iStock-1035265296-1-300x200import duty evasion.  The former employee who blew the whistle on the scheme by filing a qui tam lawsuit received 22% of the recovery as a reward.

Millions of dollars in undeclared “assists”

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Downstream wholesaler allegedly turned a blind eye to suppliers’ import fraud while receiving goods at below-market prices. Whistleblowers reap rshutterstock_214476049-300x200ewards.

The increased use of the False Claims Act to combat duty evasion has alarmed importers — as it well should!

Liability under the False Claims Act can be significant — three times damages plus penalties for each false entry document.  This is far more severe than the penalties generally awarded in U.S. Customs & Border Protection administrative proceedings.  The False Claims Act’s qui tam provisions also incentivize whistleblowers to come forward and expose import fraud by offering awards of up to 30% of the amount recovered.  Current and former employees of importers — as well as their competitors — have reaped millions of dollars in awards for filing whistleblower claims.

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Court says that disputed medical judgments present a triable issue for a jury, creating a Circuit split and pavingshutterstock_1549738514-1-300x196 the way for similar whistleblower claims.

The Third Circuit Court of Appeals has ruled that a physician’s judgments and opinions can be considered “false” under the False Claims Act, rejecting the Eleventh Circuit’s “objective falsehood” requirement and creating a Circuit split.  In United States v. Care Alternatives, the Third Circuit found that contradictory medical expert opinions as to whether patients were “terminally ill” as defined by Medicare and thus eligible for hospice care benefits raised a triable issue for the jury as to falsity under the False Claims Act and did not warrant dismissal on summary judgment.

The decision conflicts with that of the Eleventh Circuit last year in United States v. AseraCare, where the court ruled that medical expert testimony standing alone cannot prove the falsity of a clinical judgment of hospice care eligibility because “a claim cannot be ‘false’ [under the False Claims Act] if the underlying clinical judgment does not reflect on objective falsehood.”

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Opinions warn against conflating FRCP 23 elements with constitutional standing.shutterstock_579176143-1-300x150

Defendants battling proposed class actions based on alleged violations of state law have long argued that any certified class should be limited to residents of the states in which the named plaintiffs reside. Absent class members from other states should be excluded, they urge, because the named plaintiffs supposedly only have “standing” to bring claims under the laws of their own states and not others. Scores of district courts have agreed, limiting the geographical scope of classes and leaving large numbers of injured victims without relief.

Now, however, a consensus is emerging at the appellate level that this is incorrect.

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Despite whistleblower claims, federal agency insists it wasn’t defrauded

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Guardrail spears driver’s side door of car in Gurnee, IL, in 2013. Harman alleged that the crash involved Trinity’s ET-Plus guardrail.

The anti-fraud bar is focused on the upcoming oral argument in the appeal of the trial verdict in United States ex rel. Harman v. Trinity Industries Inc., calendared for Dec. 7, 2016, before the Fifth Circuit. The $663 million verdict — the largest in the history of the federal False Claims Act — raises questions going to heart of the False Claims Act’s qui tam (whistleblower) provisions.  Those provisions enable private parties who have evidence of fraud against the government to bring civil lawsuits for the recovery of damages on the government’s behalf. Successful qui tam whistleblowers receive bounties of 15-30% of what the government receives.