A federal judge said the U.S. could continue a False Claims Act case against Highmark Blue Cross and Blue Shield, Pittsburgh, using a "novel theory" of prosecution. The insurer is accused of violating federal law not by submitting false claims to Medicare but by causing claims to be incorrectly billed to Medicare. Under law, hospitals and other providers must bill Medicare second, with few exceptions, when the beneficiary also is covered by private insurance or under an auto accident or workers' compensation policy. According to prosecutors, Highmark incorrectly denied providers' bills for services, knowing the bills would then be submitted to Medicare. Highmark also is accused of other False Claims Act violations and of violating the Medicare Secondary Payer Statute both as a private insurer and a Medicare fiscal intermediary. The civil suit was filed in 2000 by a former Highmark compliance officer and joined by the U.S. attorney in Philadelphia in 2003. Highmark spokesman Michael Weinstein said the company would vigorously defend itself against the suit. "We disagree with any characterization that we intentionally underpaid claims," Weinstein said. In her 22-page ruling, U.S. District Judge Anita Brody in Philadelphia said the government is employing an unusual interpretation of the False Claims Act that has never been tested. -- by Mark Taylor
Judge allows U.S. to proceed with 'novel' false claims theory
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