Jason E. Christ, Member of the Firm in the Health Care & Life Sciences practice, in the firm’s Washington, DC, office, was quoted in Modern Healthcare, in “Legal Experts Expect 'More Scrutiny' of Medicare Prior Authorization from Feds,” by Maya Goldman. (Read the full version – subscription required.)

Following is an excerpt:

As the federal government's attention to improper Medicare Advantage prior authorization denials intensifies, insurers should consider examining their policies if they want to avoid trouble. …

The False Claims Act is generally enforced against providers that knowingly submit fraudulent claims to Medicare or Medicaid. Whether the statute also governs prior authorization denials is up for debate.

Even for situations in which it could apply, evidence that the denials and the appeals processes were so egregious that they go beyond contract violations would have to be strong, said Jason Christ, a healthcare fraud and abuse attorney at Epstein Becker Green.

But federal interest in Medicare Advantage enforcement follows a familiar pattern that often ends with the Justice Department getting involved.

"There's a lot of ingredients here that you see before what I'll call a 'sweep,'" Christ said. "You always sort of look at: How interesting would something like this be to a finder-fact jury or a judge?"

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