HHS OIG Report on MCO Institutional Status Patients
Client Alert | 1 min read | 03.11.04
The Office of the Inspector General ("OIG") of the United States Department of Health and Human Services ("HHS") released on March 9, 2004 its report on the appropriateness of Medicare payments to managed care organizations (MCOs) for beneficiaries with institutional status. The OIG used a national sample of eight statistically selected MCOs and five other MCOs that were individually audited, and found $12.8 million in unallowable payments for beneficiaries incorrectly claimed as institutionalized. The payments were unallowable, the OIG claimed, because the MCOs did not verify that the beneficiaries met residency requirements, such as (1) 30-day residency; (2) residency in a Medicare- or Medicaid-certified facility; and (3) residency in the applicable institution during the claimed time period. The OIG recommended that the Centers for Medicare & Medicaid Services ("CMS") improve oversight procedures and instruct sampled and audited MCOs to repay the identified overpayments. CMS is considering these recommendations, along with a recommendation to instruct other MCOs to conduct self-audits and refund identified overpayments. Health plan liability in the millions has previously been incurred following allegations of improper institutional status reporting. The report does not delve into a topic on which there has been disagreement -- whether institutional status patients need to be in certified beds within an institution, or only need to be in an institution with certified beds.
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Client Alert | 5 min read | 12.12.25
Eleventh Circuit Hears Argument on False Claims Act Qui Tam Constitutionality
On the morning of December 12, 2025, the Eleventh Circuit heard argument in United States ex rel. Zafirov v. Florida Medical Associates, LLC, et al., No. 24-13581 (11th Cir. 2025). This case concerns the constitutionality of the False Claims Act (FCA) qui tam provisions and a groundbreaking September 2024 opinion in which the United States District Court for the Middle District of Florida held that the FCA’s qui tam provisions were unconstitutional under Article II. See United States ex rel. Zafirov v. Fla. Med. Assocs., LLC, 751 F. Supp. 3d 1293 (M.D. Fla. 2024). That decision, penned by District Judge Kathryn Kimball Mizelle, was the first success story for a legal theory that has been gaining steam ever since Justices Thomas, Barrett, and Kavanaugh indicated they would be willing to consider arguments about the constitutionality of the qui tam provisions in U.S. ex rel. Polansky v. Exec. Health Res., 599 U.S. 419 (2023). In her opinion, Judge Mizelle held (1) qui tam relators are officers of the U.S. who must be appointed under the Appointments Clause; and (2) historical practice treating qui tam and similar relators as less than “officers” for constitutional purposes was not enough to save the qui tam provisions from the fundamental Article II infirmity the court identified. That ruling was appealed and, after full briefing, including by the government and a bevy of amici, the litigants stepped up to the plate this morning for oral argument.
Client Alert | 8 min read | 12.11.25
Director Squires Revamps the Workings of the U.S. Patent Office
Client Alert | 8 min read | 12.10.25
Creativity You Can Use: CJEU Clarifies Copyright for Applied Art
Client Alert | 4 min read | 12.10.25
Federal Court Strikes Down Interior Order Suspending Wind Energy Development
