LYNWOOD SMITH, District Judge.
Relator, Floyd H. Wilson, commenced this qui tam proceeding on behalf of the United States, alleging violations of the False Claims Act, 31 U.S.C. § 3729 et seq., by Crestwood Healthcare L.P., doing business as "Crestwood Medical Center," Dr. Smita S. Shah, Dr. James Eugene Speed, Dr. Stephen G. Tygart, Dr. Pamela Hudson, and a number of fictional defendants described only as "Does 1-25."
Relator, Floyd H. Wilson, is a Tennessee-based contractor.
Prior to December of 2000, Crestwood was owned by Healthcare Corporation of America ("HCA").
Crestwood had an affirmative obligation to ensure that its provision of healthcare and its billing policies complied with federal law, and to report any potential violations to the Department of Health and Human Services.
Crestwood entered into a "Ground Lease Agreement" with relator's development company in 1999.
One of the subtenants was a medical practice called "General Surgical Associates."
The defendant physicians were all subtenants of Crestwood for unspecified periods of time between calendar years 2000 and 2010.
Under the terms of the subleases, the subtenants were supposed to pay Crestwood their share of the operating expenses of the premises as "additional rents."
Crestwood provided custom leasehold improvements in the premises subleased by the defendant physicians.
The final paragraph in the "allegations" section of the complaint states that Crestwood "knowingly and intentionally violated Federal Law" by providing all of the compensation outlined in the complaint in exchange for illegal Medicare and Medicaid referrals from the subtenants.
Federal Rule of Civil Procedure 12(b) permits a party to move to dismiss a complaint for, among other reasons, "failure to state a claim upon which relief can be granted." Fed. R. Civ. P. 12(b)(6).
Iqbal, 556 U.S. at ___, 129 S. Ct. at 1949-50 (emphasis added).
When ruling upon a motion to dismiss, the court must assume that the well-pleaded facts set forth in the plaintiff's complaint are true. See Anza v. Ideal Steel Supply Corp., 547 U.S. 451, 453 (1994) (stating that on a motion to dismiss, the court must "accept as true the factual allegations in the amended complaint"); Marsh v. Butler County, 268 F.3d 1014, 1023 (11th Cir. 2001) (en banc) (setting forth the facts in the case by "[a]ccepting all well-pleaded factual allegations (with reasonable inferences drawn favorably to Plaintiffs) in the complaint as true"). Accordingly, that which is set out in this memorandum opinion as "the facts" for Rule 12(b)(6) purposes may, or may not, be the actual facts. See, e.g., Williams v. Mohawk Industries, Inc., 465 F.3d 1277, 1281 n.1 (11th Cir. 2006).
The pleading standard is heightened in cases involving fraud or mistake. "In alleging fraud or mistake, a party must state with particularity the circumstances constituting fraud or mistake." Fed. R. Civ. P. 9(b). Rule 9(b) serves three purposes:
Banca Cremi, S.A. v. Alex. Brown & Sons, Inc., 132 F.3d 1017, 1036 n.25 (4th Cir. 1997) (quoting Parnes v. Gateway 2000, Inc., 122 F.3d 539, 549 (8th Cir. 1997)). Claims brought pursuant to the False Claims Act are considered fraud claims, and are subject to the pleading requirements of Rule 9(b). See, e.g., United States ex rel. Matheny v. Medco Health Solutions, Inc., 671 F.3d 1217, 1222 (11th Cir. 2012).
The False Claims Act allows private citizens to bring civil actions on behalf of the United States — a so-called "qui tam action." 31 U.S.C. § 3730(b). The person bringing such an action is known as the "relator." A qui tam action does not allege that the relator personally suffered damages. Rather, the relator prosecutes the action to recover losses suffered by the United States, but is entitled to a share of any damages awarded to the government. That share ranges between fifteen and twenty-five percent, if the government decides to participate in the prosecution of the case, or twenty-five and thirty percent, if the government declines to exercise that option. See 31 U.S.C. §§ 3730(d)(1)-(2).
The False Claims Act imposes liability on persons who defraud the federal government. The statute provides for a civil penalty of between $5,000 and $10,00 to be imposed for each violation, and treble damages for losses actually suffered by the government. 31 U.S.C. § 3729(a)(1). In relevant part, the False Claims Act imposes that liability on any person who:
31 U.S.C. §§ 3927(a)(1)-(3), (7).
Congress has enacted statutory provisions to curtail fraud in the medical industry, particularly with regard to the federally-funded Medicare and Medicaid programs. The Anti-Kickback Statute, 42 U.S.C. § 1320a-7b, imposes criminal liability on anyone who, among other things,
42 U.S.C. § 1320a-7b(b)(1). The statute likewise penalizes those who make payments in return for receiving referrals. 42 U.S.C. § 1320a-7b(b)(2). Additionally, the Stark Statute, 42 U.S.C. § 1395nn, prohibits hospitals and other medical providers from presenting claims to federal health care programs if those claims are the result of referrals from physicians with whom the hospital has a financial relationship. See 42 U.S.C. § 1395nn(a)(1).
In recognition of the fact that legitimate relationships may exist between hospitals and physicians who practice in or refer patients to hospitals, exceptions and safe harbor provisions were included in both the Anti-Kickback Statute and the Stark Statute. See, e.g., 42 U.S.C. §§ 1320a-7b(b)(3); 1395nn(e). Federal regulations outline the requirements which must be met in order to submit a claim to the government, when that claim would ordinarily be barred by the statutes. See, e.g., 42 C.F.R. § 411.357(a)(4). Among other requirements, any lease agreement between a referring physician and treating hospital must be made at fair market value, and, be consistent with an arms' length transaction. See 42 U.S.C. § 1395nn(h)(3).
Relator's False Claims Act theory is premised on violations of the Anti-Kickback Statute and the Stark Statute. He avers that the lease agreements between Crestwood and the defendant physicians were arranged in exchange for patient referrals, and violated both statutes: i.e., the rent was below market value, violating the Stark Statute, and the reduced rent and other financial benefits constituted remuneration, in violation of the Anti-Kickback Statute. Thus, he alleges, any Medicare or Medicaid claims arising from referrals from the defendant physicians to Crestwood would be in contravention of federal law and, therefore, fraudulent. For the purposes of ruling on the motions to dismiss, the court will assume that relator's factual assertions regarding the lease arrangements are sufficient to establish violations of the Anti-Kickback Statute and Stark Statute.
Relator alleges violations of subsections (a)(1) and (a)(2) of the False Claims Act in Count I of his complaint. The Eleventh Circuit has consistently held that, in order to satisfy the pleading requirements of Federal Rule of Civil Procedure 9(b), a relator bringing an action under to subsection (a)(1) of the False Claims Act must allege "facts as to time, place, and substance of the defendant's alleged fraud, specifically the details of the defendants' allegedly fraudulent acts, when they occurred, and who engaged in them." Matheny v. Medco Health Solutions, Inc., 671 F.3d 1217, 1222 (11th Cir. 2012) (quoting Hopper v. Solvay Pharmaceuticals, Inc., 588 F.3d 1318, 1324 (11th Cir. 2009)). See also Corsello v. Lincare, Inc., 428 F.3d 1008, 1012 (11th Cir. 2005); United States ex rel. Clausen v. Laboratory Company of America, Inc., 290 F.3d 1301, 1310 (11th Cir. 2002).
"The False Claims Act does not create liability merely for a health care provider's disregard of Government regulations or improper internal policies unless, as a result of such acts, the provider knowingly asks the Government to pay amounts it does not owe." Clausen, 290 F.3d at 1311 (citations omitted).
Id. (emphasis in original, citation omitted). Thus, the relator must make specific allegations with regard to underlying violations of federal law: i.e., the actions that make the claims submitted to the government fraudulent, and, with regard to the claims themselves. As the Eleventh Circuit explained in Corsello,
Corsello, 428 F.3d at 1014. See also Hopper, 588 F.3d at 1326 (ruling that Rule 9(b) was not satisfied when the relator merely piled "inference upon inference" without alleging any particular details about the submission of claims); United States ex rel. Atkins v. McInteer, 470 F.3d 1350, 1359 (11th Cir. 2006) (ruling that a relator's complaint fails "for want of sufficient indicia of reliability" when it merely "portrays the scheme and then summarily concludes that the defendants submitted false claims to the government for reimbursement"). Cf. Matheny, 671 F.3d at 1225 (denying motion to dismiss where "Relators pled specifics relating to the submission of a specific statement in a specific document, submitted by a specific person during a specific review, as required by a particular government contract"); Hill v. Morehouse Medical Associates, Inc., No. 02-14429, 2003 WL 22019936, at *4-5 (11th Cir. Aug. 15, 2003) (denying motion to dismiss where relator provided detailed description of billing process, physicians and patients involved, diagnosis codes, and confidential documents containing additional information).
Actions brought pursuant to subsection (a)(2) of the False Claims Act do not require allegations that false claims were submitted to the government, because that subsection of the statute lacks the "presentment clause" that is contained in subsection (a)(1). Hopper, 588 F.3d at 1327-29 (citing Allison Engine Co. v. United States ex rel. Sanders, 553 U.S. 662 (2008)). Instead, a relator bringing a subsection (a)(2) claim must allege "that (1) the defendant made a false record or statement for the purpose of getting a false claim paid or approved by the government; and (2) the defendant's false record or statement caused the government to actually pay a false claim." Id. at 1327. "[G]eneral allegations of improper government payments to third parties, supported by factual or statistical evidence to strengthen the inference of fraud . . . could satisfy the particularity requirements of Rule 9(b)." Id. (bracketed alteration supplied). However, the Hopper court did not reach the question of whether the pleading standard for the "payment clause" of subsection (a)(2) actually is more relaxed than the high standard applied to the "presentment clause" in subsection (a)(1), because the court determined that the relator did not allege that the defendants intended for the government to rely on their false statements. Id.
Here, relator has failed to provide, or even to attempt to provide, the "who," "what," "where," "when," and "how" of fraudulent claim submissions to the government. As with the relators in Clausen, Corsello, Atkins, and Hopper, relator has provided a detailed explanation of the illegal scheme that, he alleges, precipitated false claims. But, as with the relators in the Clausen, Corsello, Atkins, and Hopper cases, he provides no details regarding the submission of any claims. Relator only makes one statement regarding the actual submission of false claims: "Defendants then knowingly submitted false claims to federal and state governments based on referrals from those physicians."
Relator alleges violations of subsection (a)(3), conspiracy to defraud the United States, in Count II of his complaint. To state a False Claims Act claim for conspiracy to defraud the government, a relator must show:
Corsello, 428 F.3d at 1014 (internal quotation and citation omitted). Subsection (a)(3) claims, like those brought under the other subsections of the False Claims Act, are subject to the heightened pleading standard of Rule 9(b). Id.
Here, relator alleges that the improper real estate dealings and patient referrals that form the basis of his claims in Count I constitute a conspiracy to defraud the government.
Relator alleges violations of subsection (a)(7) in Count III of his complaint. That subsection is the so-called "reverse false claim" provision of the False Claims Act. To assert a reverse false claim, a plaintiff must allege the existence of five elements:
United States ex rel. Mastej v. Health Management Associates, Inc., ___ F. Supp. 2d ___, No. 2:11-cv-89-FtM-29DNF, 2012 WL 523623, at *7 (M.D. Fla. Feb. 26, 2012) (citations omitted).
Here, relator has made no specific allegations to support a reverse false claim. Instead, he merely makes a conclusory assertion that defendants "used a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money to the government."
Relator's response brief, filed in opposition to the motions to dismiss, contains over four, full, single-spaced, pages of "background."
The defendant physicians jointly filed a motion to strike the response, while Crestwood and Hudson filed a reply brief, in which they urged the court to disregard the additional facts.
Defendants correctly state that, when evaluating a motion to dismiss premised upon Federal Rule of Civil Procedure 12(b)(6), courts generally does not consider allegations outside of the complaint itself. See, e.g., St. George v. Pinellas County, 285 F.3d 1334, 1337 (11th Cir. 2002) ("The scope of the review must be limited to the four corners of the complaint."). There is an exception to that general rule: i.e., when an extrinsic document is "(1) central to the plaintiff's claim, and (2) its authenticity is not challenged." Speaker v. United States Department of Health and Human Services Centers for Disease Control & Prevention, 623 F.3d 1371, 1379 (11th Cir. 2010). That exception can apply to documents referenced in the complaint, Wilchombe v. TeeVee Toons, Inc., 555 F.3d 949, 959 (11th Cir. 2009), or submitted by a defendant. Speaker, 623 F.3d at 1379. Thus, relator may rely on the language of the compliance agreements and leases in arguing that his complaint is sufficiently well-pleaded (although it would have been preferable to attach them to the complaint itself).
Nonetheless, the issue of whether relator may properly rely on documents outside the four corners of his complaint is moot. Even assuming the background information presented in relator's response is true, it fails to elevate the allegations in his complaint to the level of specificity required by the Eleventh Circuit under Rule 9(b). Relator still has failed to allege any false claims with specificity. The mere fact that the defendant physicians admitted they referred some patients to Crestwood, and had some Medicare patients, falls far short of the "who," "what," "where," "when," and "how" required to satisfy Rule 9(b). Corsello, 428 F.3d at 1014. Relator's argument that his conversations with Brown provide his allegations with sufficient indicia of reliability is stronger, but still ultimately fails.
Relator relies on two Eleventh Circuit cases: Matheny, and United States ex rel. Walker v. R&F Properties of Lake County, Inc., 433 F.3d 1349 (11th Cir. 2005).
Matheny is likewise distinguishable from the case at bar. Relator relies on Matheny to demonstrate that failure to comply with a Corporate Integrity Agreement can constitute a violation of the False Claims Act.
The differences between the specificity of the allegations in Walker and Matheny, on the one hand, and the case at bar, on the other, are striking. Perhaps most salient is the fact that, here, relator is a corporate outsider, while in those cases the relators were former employees of the defendants. There is no requirement that a relator be an employee or former employee, and the Eleventh Circuit has recognized the difficulty an outsider faces in satisfying Rule 9(b). See Clausen, 290 F.3d at 1314 ("We are not unsympathetic to the situation in which Clausen finds himself. Most relators in qui tam actions are insiders. As a corporate outsider, he may have had to work hard to learn the details of the alleged schemes. . . ."). Nonetheless, a relator, be he an insider or an outsider, still must be able to state the "who," "what," "where," "when," and "how" of claims filed with the government. Corsello, 428 F.3d at 1014. See also Clausen, 290 F.3d at 1314 (stating that the pleading standard is not relaxed for corporate outsiders). Of more legal significance than their status as insiders, the relators in Walker and Matheny alleged specific details about the filing of fraudulent claims. Relator's bare assertion that claims were filed, and that the Crestwood CFO told him that there were fraudulent claims, does not meet that standard.
Federal Rule of Civil Procedure 15 states that a "court should freely give leave [to amend] when justice so requires." Fed. R. Civ. P. 15(a)(2) (bracketed alteration supplied). "Ordinarily, a party must be given at least one opportunity to amend before the district court dismisses the complaint." Corsello, 428 F.3d at 1314 (citing Bryant v. Dupree, 252 F.3d 1161, 1163 (11th Cir. 2001)). The court may disallow amendment, however, "(1) where there has been undue delay, bad faith, dilatory motive, or repeated failure to cure deficiencies by amendments previously allowed; (2) where allowing amendment would cause undue prejudice to the opposing party; or (3) where amendment would be futile." Id. When a relator desires to amend his complaint, he must file a motion for leave to amend, and "must either attach a copy of the proposed amendment to the motion or set forth the substance thereof." Atkins, 470 F.3d at 1362.
Here, relator has not attached a copy of his proposed amended complaint. The additional factual allegations he set forth in his response to the motions to dismiss, however, appear to constitute the substance of his proposed amendment.
The complaint names various fictitious defendants, stating that those unknown people "have served as admitting physicians, agents, representatives of one and another in the fraud and submission of false and fraudulent claims to the United States."
For the reasons set forth herein, the motion to dismiss filed by defendants Speed and Tygart,
Defendants have not relied on those inconsistencies in framing their arguments in favor of dismissal. The court highlights them here only as an explanation for the omission of specifics in its statement of the facts, as relator did attempt to include specifics in his complaint.
Fed. R. Civ. P. 12(b).
The amendments to the relevant language of the statute were largely stylistic, and the current version of the statute is not substantively different from the prior version. The revised versions of the old subsections (a)(1), (a)(2), (a)(3), and (a)(7) appear at subsections (a)(1)(A), (a)(1)(B), (a)(1)(C), and (a)(1)(G), respectively, of the current 31 U.S.C. § 3927.
Id. (bracketed alterations supplied).