Implied Certification and False Claims

Imagine this – you see a patient who needs some particular treatment. You have just the person in your office to provide the service, but there is a catch; they are not licensed. No big deal, you think, they can do the service, and you, the licensed provider, will bill for it. “I know they are qualified; I know it will be right.”

No problem, right?


In this month’s Supreme Court Decision in the matter Universal Health Services v. United States ex rel. Escobar, the court addressed this issue head on. If a contractor submits claims for a service provided by an individual for reimbursement, the claims are treated as an implied certification that these individuals are qualified. If they are not, as was the case in Escobar, the claim is a fraudulent claim.

Here the court made clear that, while stating something false is fraudulent, failing to state something important also can be fraudulent.  False statements must be material, and the falsehood must be so serious that the government, had it known of the falsity, would withhold payment.  A great discussion of this case can be found at SCOTUSblog. 

The long term implications of the decision remain to be seen, but think about what you are implying when you certify that claim you are about to submit.