Justia Public Benefits Opinion SummariesArticles Posted in Government Contracts
Druding v. Care Alternatives
Former employees of Alternatives, a for-profit hospice provider, sued under the False Claims Act, 31 U.S.C. 3729, alleging that Alternatives submitted claims for Medicare reimbursement despite inadequate documentation in the patients’ medical records supporting hospice eligibility, under 42 C.F.R. 418.22(b)(2). For a patient to be eligible for Medicare hospice benefits, and for a hospice provider to be entitled to reimbursement, a patient must be certified as “terminally ill.” The district court granted Alternatives summary judgment based on lack of materiality, finding “no evidence” that Alternatives’ insufficiently documented certifications "were material to the Government’s decision to pay.” The court reasoned that “[t]he Government could see what was or was not submitted” yet never refused any of Alternatives’ claims, despite the inadequacy or missing supporting documentation or where compliance was otherwise lacking.The Third Circuit vacated. When a government contractor submits a claim for payment but fails to disclose a statutory, regulatory, or contractual violation, that claim does not automatically trigger liability. The Act requires that the alleged violation be “material” to the government’s decision to pay. The Supreme Court has identified factors to assist courts in evaluating materiality. In this case, the court based its decision principally on the government’s continued payments after being made aware of its deficient documentation, overlooking factors that could have weighed in favor of materiality— and despite an open dispute over the government’s “actual knowledge.” View "Druding v. Care Alternatives" on Justia Law
United States ex rel. Schutte v. Supervalu Inc.
Petitioners sued retail pharmacies under the False Claims Act (FCA), 31 U.S.C. 3729, which permits private parties to bring lawsuits in the name of the United States against those who they believe have defrauded the federal government and imposes liability on anyone who “knowingly” submits a “false” claim to the government. Petitioners claim that the pharmacies defrauded Medicaid and Medicare by offering pharmacy discount programs to their customers while reporting their higher retail prices, rather than their discounted prices, as their “usual and customary” charge for reimbursement. The Seventh Circuit concluded that the pharmacies could not have acted “knowingly” if their actions were consistent with an objectively reasonable interpretation of the phrase “usual and customary.”The Supreme Court vacated. The FCA’s scienter element refers to a defendant’s knowledge and subjective beliefs—not to what an objectively reasonable person may have known or believed. The FCA’s three-part definition of the term “knowingly” largely tracks the traditional common-law scienter requirement for claims of fraud: Actual knowledge, deliberate ignorance, or recklessness will suffice. Even though the phrase “usual and customary” may be ambiguous on its face, such facial ambiguity alone is not sufficient to preclude a finding that the pharmacies knew their claims were false. View "United States ex rel. Schutte v. Supervalu Inc." on Justia Law
Sibley v. University of Chicago Medical Center
Plaintiffs worked for MBO and Trustmark, which provide medical billing and debt‐collection services to healthcare providers. After they raised concerns about their employers’ business practices, the plaintiffs were fired. They sued MBO, Trustmark, and MBO's client, the University of Chicago Medical Center (UCMC), under the False Claims Act, 31 U.S.C. 3729. Regulations specify that Medicare providers seeking reimbursement for “bad debts” owed by beneficiaries must first make reasonable efforts to collect those debts. The plaintiffs claim that UCMC knowingly avoided an obligation to repay the government after it effectively learned that it had been reimbursed for non-compliant debts; MBO and Trustmark caused the submission of false claims to the government. Each plaintiff also claimed retaliation.The Seventh Circuit affirmed the dismissal of the complaint, in part. The district court properly dismissed the claim against UCMC, which neither had an established duty to repay the government nor acted knowingly in avoiding any such duty. The direct false claim against MBO was also correctly dismissed. The complaint failed to include specific representative examples of non-compliant patient debts, linked to MBO, for which reimbursement was sought. The court reversed in part; the complaint includes specific examples of patient debts involving Trustmark. Two plaintiffs alleged facts that support the inference that they reasonably believed their employers were causing the submission of false claims. View "Sibley v. University of Chicago Medical Center" on Justia Law
United Healthcare of Mississippi Inc. et al. v. Mississippi’s Community Mental Health Commissions, et al.
In 2012, United Healthcare of Mississippi (United) entered into provider agreements with Mississippi’s fourteen Community Mental Health Centers (CMHCs) to provide Medicaid services under the Division of Medicaid’s (DOM’s) managed care program. From 2012 until 2019, United paid the CMHCs an agreed upon amount for Medicaid services - 100 percent of the medicaid fee schedule rates. In July 2019, United unilaterally imposed a 5 percent rate cut, retroactive to January 1, 2019, and later demanded that the CMHCs refund 5 percent of all payments made from July 1, 2018, through December 31, 2018, all of which totaled more than $1 million. The CMCHs demanded that United immediately cease and desist from the 5 percent rate cut and recoupments. When United refused, the CMHCs filed a Complaint for Damages and Injunctive Relief, specifically requesting, inter alia, a preliminary injunction. United responded with a motion to compel arbitration and to stay the proceedings. After a two-day evidentiary hearing, the circuit court denied United’s motion to compel arbitration, granted the CMHCs’ request for injunctive relief, and issued a preliminary injunction. The limited issues presented to the Mississippi Supreme Court were whether the trial court properly enjoined United from imposing a 5 percent rate cut and whether the trial court erred by denying arbitration. After review, the Supreme Court affirmed the trial court’s decision to grant a preliminary injunction and to deny the motion to compel arbitration. View "United Healthcare of Mississippi Inc. et al. v. Mississippi's Community Mental Health Commissions, et al." on Justia Law
Magnolia Health Plan, Inc. et al. v. Mississippi’s Community Mental Health Commissions, et al.
Magnolia, a managed care organization that contracted with the State to provide Medicaid services, applied what it saw as a statutory five percent reduction in Medicaid rates to Mississippi’s fourteen regional mental health providers. The regional providers responded by filing a complaint against Magnolia in which they sought injunctive relief and monetary damages. On February 18, 2020, Magnolia Health Plan, Inc., and Cenpatico Behavioral Health, LLC (collectively, “Magnolia”), filed a timely notice of appeal after a circuit court denied Magnolia’s motion to compel arbitration, and granted a preliminary injunction against it in favor of Defendants, Mississippi’s fourteen regional health commissions. The notice of appeal included both orders. As to the first, the order denying Magnolia’s motion to compel arbitration, at oral argument before the Mississippi Supreme Court panel, Magnolia abandoned the issue. As to the second, the order granting Magnolia’s request for a permanent injunction, the order was not a final, appealable judgment. Accordingly, the Supreme Court concluded it did not have jurisdiction for further review. View "Magnolia Health Plan, Inc. et al. v. Mississippi's Community Mental Health Commissions, et al." on Justia Law
Owsley v. Fazzi Associates., Inc.
Owsley. a nurse for Care Connection, a company providing home healthcare to Medicare patients, alleged that she observed, firsthand, documents showing that her employer had used fraudulent data from Fazzi to submit inflated claims for payment to the federal and Indiana state governments. She sued both companies under the False Claims Act, 31 U.S.C. 3729(a)(1)(A), (B), (C), (G), and an Indiana statute.The Sixth Circuit affirmed the dismissal of the suit. Owsley’s complaint provided few details that would allow the defendants to identify any specific claims—of the hundreds or likely thousands they presumably submitted—that she thinks were fraudulent, and did not meet the requirements of Civil Rule 9(b). While Owsley’s allegations describe, in detail, a fraudulent scheme: Fazzi fraudulently upcoded patient data, which Care then used to submit inflated requests for anticipated Medicare payments, that information does not amount to an allegation of “particular identified claims” submitted pursuant to the fraudulent scheme. View "Owsley v. Fazzi Associates., Inc." on Justia Law
Prose v. Molina Healthcare of Illinois,
Molina Healthcare contracted with the Illinois Medicaid program to provide multiple tiers of medical-service plans with scaled capitation rates (fixed per-patient fees that cover all services within the plan’s scope). The Nursing Facility plan required Molina to provide Skilled Nursing Facility (SNF) services. Molina subcontracted with GenMed to cover that obligation. Molina received a general capitation payment from the state, out of which it was to pay GenMed for the SNF component. Molina breached its contract with GenMed. GenMed terminated the contract. After GenMed quit, Molina continued to collect money from the state for the SNF services, but it was neither providing those services itself nor making them available through any third party. Molina never revealed this breakdown, nor did it seek a replacement service provider.Prose, the founder of GenMed, brought this qui tam action under both the state and federal False Claims Acts, 31 U.S.C. 3729, alleging that Molina submitted fraudulent claims for payments from government funds. The district court dismissed the case. The Seventh Circuit reversed. The complaint plausibly alleges that as a sophisticated player in the medical-services industry, Molina was aware that these kinds of nursing facility services play a material role in the delivery of Medicaid benefits. View "Prose v. Molina Healthcare of Illinois," on Justia Law
Yarberry v. Supervalu Inc.
A False Claims Act, 31 U.S.C. 3729(a)(1)(A), “qui tam” lawsuit against SuperValu claimed that SuperValu knowingly filed false reports of its pharmacies’ “usual and customary” (U&C) drug prices when it sought reimbursements under Medicare and Medicaid. SuperValu listed its retail cash prices as its U&C drug prices rather than the lower, price-matched amounts that it charged qualifying customers under its discount program. Medicaid regulations define “usual and customary price” as the price charged to the general public. The district court held that SuperValu’s discounted prices fell within the definition of U&C price and that SuperValu should have reported them but held that SuperValu did not act with scienter.The Seventh Circuit affirmed, joining other circuits in holding that the Supreme Court’s 2007 “Safeco” interpretation of the Fair Credit Reporting Act’s scienter provision applies with equal force to the False Claims Act’s scienter provision. There is no statutory indication that Congress meant its usage of “knowingly,” or the scienter definitions it encompasses, to bear a different meaning than its common-law definition. SuperValu did not act with the requisite knowledge. SuperValu’s interpretation of “usual and customary price” was objectively reasonable under Safeco. View "Yarberry v. Supervalu Inc." on Justia Law
New LifeCare Hospitals of North Carolina LLC v. Becerra
In 2008, four long-term care hospitals that treat patients who are dually eligible for the Medicare and Medicaid programs were denied reimbursement by the Secretary of Health and Human Services for “bad debts,” unpaid coinsurances and deductibles owed by patients. The Secretary denied reimbursement on the grounds that the hospitals failed to comply with the “must-bill” policy, 42 C.F.R. 413.89(e)(2), which requires hospitals to bill the state Medicaid program to determine whether Medicaid will cover the bad debts first, and obtain a “remittance advice” indicating whether the state “refuses payment,” before seeking reimbursement under Medicare. uring the relevant time period, the hospitals were not enrolled in Medicaid and were unable to bill their state Medicaid programs; they claim they were previously reimbursed and that there was an abrupt policy change.The D.C. Circuit affirmed summary judgment for the Secretary, concluding that substantial evidence supported a finding that there was no change in policy. The court rejected arguments that the denial decision impermissibly required them to enroll in Medicaid, despite the fact that Medicaid participation is voluntary, and was arbitrary. View "New LifeCare Hospitals of North Carolina LLC v. Becerra" on Justia Law
Rahimi v. Rite Aid Corp.
Rite Aid’s “Rx Savings Program” provides generic prescription drugs at reduced prices. The program is free and widely available but excludes customers whose prescriptions are paid by publicly funded healthcare programs like Medicare or Medicaid. Federal regulations require pharmacies to dispense prescriptions for beneficiaries of those programs at their “usual and customary charge to the general public” (U&C rate). Rahimi alleged that Rite Aid overbilled the government programs because the amounts it charged did not take into account the lower Rx Savings Program prices. Rahimi claimed Rite Aid's submission of bills for those covered by publicly funded health insurance, representing the price to be the U&C rate, violated the False Claims Act, 31 U.S.C. 3729(a).The Sixth Circuit affirmed the dismissal of Rahimi’s claim. The Act’s public disclosure bar precludes qui tam actions that merely feed off prior public disclosures of fraud. From the beginning, communications about the Rx Savings Program have stated that publicly funded health care programs were ineligible for the discounted prices. Before Rahimi’s disclosures, Connecticut investigated membership discount prices; the Department of Health and Human Services announced that it would review Medicaid claims for generic drugs to determine the extent to which large chain pharmacies are billing Medicaid the usual and customary charges for drugs provided under their retail discount generic programs; and a qui tam action was unsealed in California, describing an identical scheme. View "Rahimi v. Rite Aid Corp." on Justia Law