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Implied False Certification Split Widens

Client Alert | 1 min read | 06.12.15

In U.S. v. Sanford-Brown, Ltd. (June 8, 2015), the Seventh Circuit rejected the implied false certification theory of False Claims Act liability, holding that alleged noncompliance with Title IV restrictions incorporated into a program participation agreement (PPA) for the Department of Education's subsidies program was insufficient to trigger FCA liability absent evidence that the defendant's application to establish initial Title IV eligibility was fraudulent. Although the majority of circuits have expressly adopted some form of the implied false certification theory of liability, the court joined the Fifth Circuit as the holdouts in rejecting the theory, explaining that "it would be . . . unreasonable for us to hold that an institution's continued compliance with the thousands of pages of federal statutes and regulations incorporated by reference into the PPA are conditions of payment for purposes of liability under the FCA."


Insights

Client Alert | 6 min read | 04.29.26

CMS Seeks to Expand Interoperability Requirements to Drug Pre-Authorization (FAQ)

On April 10, 2026, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule (2026 CMS Interoperability Standards and Prior Authorization for Drugs, or CMS-0062-P) outlining the agency’s plans to impose new interoperability requirements on payors participating in certain Medicare and Medicaid programs. As described by the agency in a recent press release, the proposed rule “builds on” prior rulemaking by clarifying and enhancing interoperability requirements for payors’ prior authorization processes, specifically those associated with coverage requests for pharmaceutical therapies....