Today, HHS announced goals and a timeline to move the Medicare program toward paying for the quality – not quantity – of healthcare provided to patients.

Although HHS anticipates “better, smarter, healthier” results, this move could give whistleblowers ammunition to bring quality-of-care and worthless-services lawsuits under the False Claims Act.  FCA claims are often tested against whether the alleged violations are tied to federal payment, and if quality-of-care standards become Medicare conditions of payment – not only Medicare conditions of participation – providers face an increased risk of FCA allegations related to claims for alleged substandard care.

According to HHS, this is “the first time in the history of the Medicare program that HHS has set explicit goals for alternative payment models and value-based payments.” The goals include:

  • Tying 30% of traditional fee-for-service Medicare payments to quality or value through alternative payment models like ACOs or bundled-payment arrangements by the end of 2016, and tying 50% of payments to these models by the end of 2018.
  • Tying 85% of traditional Medicare payments to quality or value through programs like the Hospital Value-Based Purchasing and the Hospital Readmissions Reduction programs by the end of 2016, and tying 90% of payments to these models by the end of 2018.

Read more about quality-of-care theories of FCA liability in our posts “Hefty settlement for ‘worthless’ claims” and “Services ‘worth less’ not ‘worthless’ false claims.”  

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