In 2024, federal courts issued a number of important decisions in False Claims Act (FCA) cases that are particularly noteworthy for the health care and life sciences industries. We focus here on decisions that further develop the FCA scienter standard addressed in 2023 by the Supreme Court in its important SuperValu decision. We also look at decisions that have accepted the invitation of three Supreme Court justices to reexamine the constitutionality of the FCA's qui tam provisions. Finally, a circuit split on the interpretation of "causation" for FCA suits based on alleged violations of the Anti-Kickback Statute (AKS) remains unresolved, pending a decision from the First Circuit.
Post-SuperValu Developments Concerning the FCA's Scienter Standard
An essential element of any FCA claim is "knowledge" that the submission of claims was "false or fraudulent." By statute, the FCA defines "knowledge" to mean that a person acted with (i) actual knowledge, (ii) deliberate ignorance, or (iii) reckless disregard with respect to the truth or falsity of the information at issue. This is the FCA's intent or scienter standard. Last year, in SuperValu, the Supreme Court held that the FCA's "knowledge" element is based on subjective intent and not, as a number of circuits had previously held, on a defendant's "objectively reasonable" interpretation of an ambiguous legal or regulatory issue.1 We previously discussed the SuperValu case (here and here) and analyzed the decision's implications in last year's issue of EnforceMintz.
The Supreme Court explained that the FCA's scienter requirement could be met by showing (i) "deliberate ignorance," meaning that a defendant had knowledge of a "substantial risk" that its statements were false but "intentionally avoid[ed]" a relevant legal or regulatory requirement; or (ii) "reckless disregard," meaning that a defendant understood that there was a "substantial and unjustifiable risk" that its claims were false but submitted the claims anyway. While the Supreme Court did not define how lower courts might determine which risks are "substantial" or "unjustifiable," these two new glosses on "deliberate ignorance" and "reckless disregard" offer some guidance to providers and companies seeking to avoid exposure to FCA liability through well-designed compliance programs.
SuperValu may have been initially understood as a clear-cut victory for the United States and private whistleblowers who bring actions under the qui tam provisions of the FCA. Generally speaking, in litigation, a defendant's subjective knowledge is often a question of fact, which makes it difficult for defendants to win a motion to dismiss on the basis of whether a complaint adequately alleges knowledge. But as decisions from the past year demonstrate, that is not the full story, for two reasons.
First, even after SuperValu, courts have been willing to grant motions to dismiss on scienter grounds. For example, in August 2024, a federal district court granted a pharmaceutical manufacturer's motion to dismiss an FCA complaint for failure to adequately allege scienter.2 In US ex rel. Sheldon v. Forest Laboratories, LLC, the relator alleged that Forest Laboratories overcharged the government in violation of the FCA because it did not include certain price concessions in calculating "best price," as that term was defined by statute. The court found the "best price" definition "no more informative than the hypothetical instruction in [SuperValu] to drive at a 'reasonable' speed."3 As such, the court found that the defendant's alleged familiarity with such vague instructions did not provide a basis to attribute a culpable mental state to the drug manufacturer.
Second, in June 2024, the Supreme Court decided Loper Bright Enterprises v. Raimondo, ending the era of "Chevron deference" in which courts deferred to an agency's interpretation of an ambiguous statute.4 This decision may lend support to FCA defendants in cases where the conduct at issue allegedly violated an ambiguous statutory or regulatory requirement. Often in FCA cases, the United States or a private relator attempts to establish scienter by showing an FCA defendant's knowledge of statutory or regulatory requirements or agency guidance. After Loper Bright, a provider or company facing ambiguous or complex statutory or regulatory requirements can now demonstrate that it subjectively believed it was not taking "substantial and unjustifiable risk" that its claims were false based on the controlling statutory text, without undue deference to an agency's interpretation. For example, analyzing Stark Law compliance often requires a review of layers of exceptions to complex statutory or regulatory prohibitions. Loper Bright may help provide a defense as to both scienter and falsity where theories of liability are premised on noncompliance with a web of statutory requirements, regulations, and complex agency guidance.
As we previously discussed (here), these case law developments highlight three implications for health care and life sciences companies seeking to minimize FCA exposure or to defend against an FCA investigation or litigation:
- Providers and companies should seek to minimize potential FCA exposure by documenting interpretations of ambiguous legal requirements or regulations based on all available advice communications with agencies or payors, and any other information when making business decisions that involve claims to federal programs or federal funds.
- In the event of an FCA investigation, strong...
