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DOJ accuses provider of failure to comply with investigation

The Department of Justice (DOJ) has petitioned the court to force provision of oral testimony deemed "relevant to a false claims law investigation." The government has accused a group that sponsors Medicare Part C insurance plans of "knowingly disregarding its duty to ensure the validity of data it submitted to Medicare for purposes of calculating" payments.

The government has sought testimony about three topics from corporate representatives to "expedite this investigation." The topics include questions about auditing procedures used to determine submitted diagnosis codes for four sample beneficiaries. Second, whether the polices, procedures and training regarding provider-submitted and chart review-generated diagnosis codes were valid and finally whether the personnel ensured compliance with these policies, procedures and training methods. The government questions whether the group investigated provider-submitted diagnosis codes unsupported by chart review results. It contends a failure to do so would support its allegations of a False Claims Act violation.

If the government can establish the testimony requested is relevant, it could force the group to comply with the request. This is completed through a Civil Investigative Demand (CID), a type of administrative subpoena.

What can other groups learn from this case? In some instances, a group can fight back when the government requests testimony or other forms of evidence. Groups that face such a request could consider three potential arguments against cooperation. First, the group could argue the issuing agency does not have authority to make the request. Another option involves the argument the information requested is irrelevant. Finally, the group could successfully block the request if it could establish the request is unreasonable or unduly burdensome upon the group.

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