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Can a Physician’s Medical Judgment be Basis for a False Claims Action? Appellate Court Rules Yes.

In a recent decision, United States ex rel. Polukoff v. St. Mark's Hospital, the Tenth Circuit held that a physician's medical judgement regarding courses of treatment may serve as the basis for False Claim Act ("FCA") liability. Interpreting the FCA broadly, the court ruled that statements of opinion made by a physician are not automatically excluded from forming the basis of FCA liability.

The court emphasized that there is no bright-line rule stating that medical judgment is exempt from FCA liability. Thus, a doctor's certification or medical judgment regarding a certain treatment can be considered "false" if the treatment is not considered "reasonable and necessary" under the government's definition, even if the terms are not defined for the specific medical treatment.

This distinction broadens the scope of liability and potential for legal action against doctors who use their best judgment when practicing medicine and executing procedures they believe to be life-saving. Physicians and health care providers must be aware of the government's definitions and interpretations of "reasonable and necessary" to ensure compliance with the FCA and avoid claims of fraud.

If you require expert legal guidance with respect to a FCA claim, please do not hesitate to call one of the experienced healthcare attorneys at (212) 668-0200 or email the firm at info@mdrxlaw.com

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Wednesday, November 21, 2018