U.S. ex rel. Ryan v. Lederman (Summary)

FALSE CLAIMS ACT

U.S. ex rel. Ryan v. Lederman, No.04-CV-2483 (E.D. N.Y. May 13, 2014)

The United States District Court for the Eastern District of New York denied in part and granted in part the federal government’s motion for summary judgment in a False Claims Act (“FCA”) suit brought against a physician.  The government claimed that the physician performed over 300 below-the-neck stereotactic radiosurgeries and billed them to Medicare despite local coverage determinations by the Part B carrier that below-the-neck stereotactic radiosurgeries were not covered.

In ruling on the government’s motion for summary judgment, the court concluded that the physician’s claims were false for two separate reasons.  First, since the Medicare Part B carrier’s local coverage determination was conclusive, the physician’s submission of claims for the below-the-neck stereotactic radiosurgery procedures was false.  Second, the physician’s coding of the procedures made his claims for payment false because the codes used did not cover procedures performed below the neck.  Nonetheless, the court held that whether the doctor had knowledge (for FCA purposes) that he was submitting false claims could not be resolved on summary judgment even though the physician received feedback, and was thus on notice, that below-the-neck procedures were not reimbursable under Part B.

However, the court granted the government’s motion for summary judgment for its payment based on mistake of fact and unjust enrichment claims against the physician.  The court pointed out that these claims were essentially duplicates of the FCA claim, but without the intent requirement.