United States ex rel. Mikes v. Straus case brief

United States ex rel. Mikes v. Straus case brief summary
274 F.3d 687 (2001)

CASE SYNOPSIS

Plaintiff employee sued defendant health care providers under the False Claims Act, 31 U.S.C.S. § 3729 et seq., alleging that they requested Medicare reimbursement for medical procedures performed in a substandard manner. The United States District Court for the Southern District of New York granted the providers summary judgment and awarded attorney fees. Both parties appealed.

CASE FACTS
The employee argued that submitting Medicare reimbursement claims for spirometry procedures not performed in accordance with the relevant standard of care violated the False Claims Act. A cause of action based on an express false certification theory failed as the employee only challenged the quality of the spirometry tests, not the decisions to order the procedure for patients. The employee failed to support her contention that the tests were not medically necessary and proffered no evidence that the providers had not personally furnished the tests as required by the Medicare reimbursement forms. 

DISCUSSION

• Acknowledging the viability of an implied certification theory for liability, the appellate court held that the 42 U.S.C.S. § 1395y(a)(1)(A) claim did not succeed as the employee had only contended that the performance of spirometry was qualitatively deficient. 
• Since 42 U.S.C.S. § 1320c-5(a) did not expressly condition payment on compliance with its terms, the providers' certification on the Medicare forms were not legally false. 
• The worthless services claim failed as the employee did not show that the providers knew that their claim forms were false. The attorney fee award was upheld.

CONCLUSION

The judgment was affirmed.

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