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Court Determines Reimbursement Expert Not Needed

September 11, 2013

On August 28, 2013, a three-judge panel for the U.S. Court of Appeals for the Seventh Circuit determined that Wisconsin doctor, Dr. Toby Watson, can press on with his suit under the federal False Claims Act even without the aid of a reimbursement expert.  Dr. Watson alleges that Dr. Jennifer King-Vassel, a child psychiatrist, wrote off-label prescriptions causing the submission of unlawful Medicaid reimbursements.  Off-label prescriptions are written for purposes not approved by the Food and Drug Administration (FDA) after the drug has been approved for at least one use.  It is a common and legal practice of physicians when they find the drug useful for another purpose.  However, Dr. Watson argues that medications prescribed for non-FDA approved purposes are not eligible for Medicaid reimbursement and that Dr. King-Vassel caused false Medicaid claims to be submitted since she knew her patient was on Medicaid.

A federal district court granted summary judgment to King-Vassel, halting Watson’s suit because he failed to use an expert to explain the Medicaid reimbursement system with regard to prescription drugs.  However, the Court of Appeals for the Seventh Circuit reversed after determining that Watson must only show that King-Vassel was aware, or should have been aware, of facts that would lead a reasonable person to realize that she was submitting or causing the submission of false claims.  The panel determined that “a reasonable jury could plausibly interpret the evidence Watson assembled to show that King-Vassel recklessly disregarded the fact that [her patient] received Medicaid assistance, and that claims for payment for his prescriptions would be submitted to Medicaid.”  The panel continued by stating, “[…] we do not think a jury needs expert testimony to understand that writing a prescription to a person insured by Medicaid will likely cause a claim to be filed with Medicaid.”

To report healthcare fraud, please contact Frohsin & Barger.

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