AHA files brief in FCA case involving retrospective review of medical judgments

The AHA today filed a friend-of-the-court brief in United States ex rel. Berntsen v. Prime Healthcare Services et al., urging the federal court “to approach short hospital stay claims with sensitivity to the difficulties and consequences hospitals, physicians and patients face when navigating the uncertain world of Medicare’s applicable coverage.” The case “is the latest in a series of attempts by qui tam relators and government auditors and attorneys to retrospectively review the medical judgments and clinical predictions that physicians make every day against an ambiguous standard that the Centers for Medicare & Medicaid Services has struggled unsuccessfully to refine and clarify,” the brief notes. “…It has become a no win situation for those physicians attempting to provide their patients with the highest appropriate quality of care within the benefits defined for them by Medicare. Against this backdrop, it is critical in False Claims Act litigation that the government specifically articulate the clinical criteria to explain why specific patients should have been placed in outpatient observation status rather than treated as inpatients and anchor that explanation in clear statements of coverage policy previously articulated by CMS.”