CopyPublished | Court of Appeals for the Eleventh Circuit
...Most notably for purposes of this appeal, the certification must be
accompanied by “[c]linical information and other documentation that support the
medical prognosis,” and such support “must be filed in the medical record with the
written certification.” 42 C.F.R. § 418.22(b)(2).
An initial certification conforming to these requirements is valid for a period
of ninety days....
...hospice eligibility requirements, which are set out in the federal Medicare statute,
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Case: 16-13004 Date Filed: 09/09/2019 Page: 26 of 57
42 U.S.C. § 1395f, and its implementing regulation, 42 C.F.R. § 418.22....
...§ 1395y(a)(1)(C).
The implementing regulations echo the language of the statute, reiterating
that each written certification of terminal illness “will be based on the physician’s
or medical director’s clinical judgment regarding the normal course of the
individual’s illness.” 42 C.F.R. § 418.22(b). See also 42 C.F.R. § 418.22(a)(1)
(stating “general rule” that hospice provider “must obtain written certification of
terminal illness” for each claimed period of care).
The regulations go on to identify several requirements for the submission of
claims....
...First, and most significant to this appeal, “[c]linical information and other
documentation that support the medical prognosis must accompany the
certification and must be filed in the medical record with the written certification.”
42 C.F.R. § 418.22(b)(2). Second, the certifying physician must include with the
certification “a brief narrative explanation of the clinical findings that supports a
life expectancy of 6 months or less.” 42 C.F.R. § 418.22(b)(3)....
...This narrative
explanation “must reflect the patient’s individual clinical circumstances and cannot
contain check boxes or standard language used for all patients.” 42 C.F.R.
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Case: 16-13004 Date Filed: 09/09/2019 Page: 30 of 57
§ 418.22(b)(3)(iv).7 And third, in deciding whether to certify a patient as
terminally ill, a physician is obligated to consider several factors: the patient’s
primary terminal condition and related diagnoses; current subjective and objective
m...
...ds”
for each patient, created “a factual dispute as to whether ‘[c]linical information and
other documentation’ in the medical record ‘support[ed] the medical prognosis’ of
a life expectancy of six months or less.” (Citing 42 C.F.R. § 418.22(b)(2).)
We conclude that the Government’s framing of the eligibility inquiry is not
consistent with the text or design of the law. The relevant regulation requires only
that “clinical information and other documentation that support the medical
prognosis . . . accompany the certification” and “be filed in the medical record.”
42 C.F.R. § 418.22(b)(2) (emphases added). This “medical prognosis” is, itself,
“based on the physician’s . . . clinical judgment.” 42 C.F.R. § 418.22(b)....
...It follows that when a hospice provider submits a claim that certifies that a
patient is terminally ill “based on the physician’s or medical director’s clinical
judgment regarding the normal course of the individual’s illness,” 42 U.S.C.
§ 1395f(7), 42 C.F.R. § 418.22(b), the claim cannot be “false”—and thus cannot
trigger FCA liability—if the underlying clinical judgment does not reflect an
objective falsehood.
Objective falsehood can be shown in a variety of ways....
CopyPublished | Florida 2nd District Court of Appeal
...1st DCA 1985)).
The legislative enactment that grants Tri-Par's authority as a taxing district
is the Enabling Act. And while the Enabling Act grants the Board the power to
promulgate rules and regulations, it does not provide the power to enforce the rules and
regulations. Cf. § 418.22(8), Fla....
