RUBEN CASTILLO, District Judge.
Robert S. Goldberg, M.D.
In earlier proceedings in this case, this Court dismissed Relators' complaint for lack of subject matter jurisdiction pursuant to Federal Rule of Civil Procedure 12(b)(1). Goldberg v. Rush Univ. Med. Ctr. (Goldberg I), 748 F.Supp.2d 917 (N.D.Ill.2010). Relators appealed, and the Seventh Circuit vacated and remanded the dismissal. United States ex rel. Goldberg v. Rush Univ. Med. Ctr. (Goldberg II), 680 F.3d 933 (7th Cir.2012). The Seventh Circuit held that Relators' allegations that Defendants misrepresented the "immediate availability" of teaching physicians during overlapping surgeries were not subject to the public disclosure bar to qui tarn suits. Id. at 935-36. Specifically, the Seventh Circuit held that Relators' allegations were not "substantially similar" to the disclosures made public by a Government Accountability Office report and the Physicians at Teaching Hospitals ("PATH") audits. Id. (citing United States ex rel. Baltazar v. Warden, 635 F.3d 866 (7th Cir. 2011)). Upon remand, Relators filed a Fourth Amended Complaint. Presently before the Court are Defendants' motions to dismiss. For the reasons discussed below, MOR's and Doctor Defendants' motion is granted in part and denied in part, and Rush's motion is granted.
Relators rely upon three sets of rules and regulations pertaining to overlapping surgeries: (1) the Medicare regulation entitled "Physician fee schedule payment for services of teaching physicians" ("Teaching Physician Regulations"), 42 C.F.R. § 415.172; (2) applicable billing rules in the May 30, 1996, Health Care Financing
RUMC is a teaching hospital that provides medical care to Medicare and Medicaid beneficiaries. (R. 168, Fourth Am. Compl. ¶ 14.) As a teaching hospital, Rush
In the context of surgeries, reimbursement under Medicare Part B requires that the teaching physician is physically present during all "key and critical" portions of the surgical procedure and is otherwise "immediately available" for the entire surgical procedure — not involved in another procedure from which he or she cannot return. 42 C.F.R. § 415.172; 1996 Medicare Rules. The Medicare Rules and Regulations instruct that when surgeries overlap, the teaching physician, in addition to being physically present during the key or critical portions of both operations, must "personally document in the medical record that he/she was physically present during the critical or key portion(s) of both procedures," and, if she will not be immediately available, she "must arrange for another qualified surgeon to immediately assist the resident in the other case should the need arise." 2002 Medicare Rules § 15016(C)(4)(a)(2).
Relators allege that between 1996 and 2004, Defendants submitted claims to Medicare that violated the Medicare Rules and Regulations by failing to follow the required procedures for overlapping surgeries. (R. 168, Fourth Am. Compl. ¶ 67.) In support of their claims, Relators describe several surgeries for which Medicare was allegedly billed that appear to violate the relevant Rules and Regulations. These include a surgery in which the billing doctor never entered the operating room; six complex surgeries scheduled to be performed by the same surgeon in two separate operating rooms over the course of a day; a surgery in which the resident performed the procedure in its entirety;
Relators allege that Doctor Defendants' regular practice was to conduct simultaneous surgeries in two or more operating rooms on each day they were operating without arranging for a back-up physician to be immediately available when they were involved in overlapping surgeries. (Id. ¶¶ 69-74, 81-82.) According to Relators, it was the practice of the orthopedic residents to lie in the medical records and state that MOR doctors were present for all key and critical portions of the surgery and that the scheduled surgeon was "immediately available" at all times. (Id. ¶ 80.) Additionally, the Rush orthopedic nurses facilitated and covered up the simultaneous surgeries by failing and refusing to note the times at which Doctor Defendants entered and exited their surgeries, even after they were instructed by their supervisors to do so. (Id. ¶¶ 75-79.) Relators also allege that the MOR doctors were motivated to increase the number of surgeries they performed to justify millions of dollars in kickbacks from Zimmer, a manufacturer and developer of surgical hip and knee implants. (Id. ¶¶ 60-63.)
Dr. Goldberg repeatedly communicated with senior Rush officials between 1999 and 2004 about the lack of surgeon supervision over residents, and he informed Rush that such conduct violated Medicare regulations. (Id. ¶ 55.) Relators claim that Rush knew the surgeries being billed by MOR doctors were not being properly supervised, but they allowed and assisted the scheduling of concurrent surgeries and obtained reimbursement from the government for surgeries that they knew did not comply with the Medicare Rules and Regulations. (Id. ¶¶ 31-34, 57.) Relators also allege that Defendants conspired to fraudulently bill Medicaid and Medicare in order to receive additional federal funds, benefit from kickback programs, and reap the financial and reputational benefits accrued by such a high volume of surgeries. (Id. ¶¶ 52-54, 58-60.)
Relators filed suit in this case under seal on July 12, 2004, alleging violations of both the FCA and the IWRPA by RUMC and MOR. (R. 1, Compl.) Relators subsequently filed an Amended Complaint on November 1, 2005, adding SurgiCenter and Dr. Cole as defendants, (R. 7, Am. Compl.), a Second Amended Complaint on June 13, 2006, (R. 8, Second Am. Compl.), and a Third Amended Complaint on June 21, 2010, adding Dr. Sheinkop, Dr. Berger, Dr. Rosenberg, Dr. Delia Valle, and Dr. Paprosky as defendants. (R. 36, Third Am. Compl.) The case was unsealed on March 5, 2010. (R. 17, Jt. Status Report at 2.)
On July 20, 2010, MOR and Doctor Defendants filed a motion to dismiss under Rule 12(b)(1) and, alternatively, Rules 12(b)(6) and 9(b). (R. 68, MOR's & Drs.' First Mot. Dismiss.) On July 27, 2010,
On August 31, 2012, Relators filed their Fourth Amended Complaint ("Complaint"). (R. 168.) Counts I and II respectively allege violations of the FCA, 31 U.S.C. §§ 3729-32, and the IWRPA, 740 Ill. Comp. Stat. 175/3(a)(1), (2), by MOR and Doctor Defendants for knowingly making and submitting to the United States and the State of Illinois false claims and claims that did not comply with Medicare Rules and Regulations. (Id. ¶¶ 165-86.) Counts III and IV respectively allege violations of the FCA and the IWRPA by Rush for permitting MOR doctors to schedule improperly supervised concurrent surgeries, knowingly submitting false claims to the United States and the State of Illinois, and perpetuating the fraudulent billing scheme. (Id. ¶¶ 187-204.) Count V alleges a conspiracy to violate the FCA and IWRPA by all Defendants. (Id. ¶¶ 206-08.)
On September 21, 2012, Doctor Defendants and MOR moved to dismiss the Complaint pursuant to Rules 12(b)(6) and 9(b), (R. 169, MOR's & Drs.' Mot. Dismiss), as did Rush, (R. 171. Rush's Mot. Dismiss). Defendants argue that the Complaint fails to meet the heightened pleading standard of Rule 9(b) and fails to state a claim against them under the Act. (R. 169, MOR's & Drs.' Mot. ¶¶ 4-6; R. 171, Rush's Mot. at 1-2.) Additionally, Drs. Berger, Rosenberg, and Sheinkop argue that the claims against them are time-barred. (R. 169, MOR's & Drs.' Mot. ¶ 3.)
A motion under Rule 12(b)(6) "challenges the sufficiency of the complaint to state a claim upon which relief may be granted." Hallinan v. Fraternal Order of Police of Chi. Lodge No, 7, 570 F.3d 811, 820 (7th Cir.2009). When reviewing a Rule 12(b)(6) motion to dismiss, the Court accepts as true all well-pleaded factual allegations in the complaint and draws all reasonable inferences in the non-movant's favor. Erickson v. Pardus, 551 U.S. 89, 94, 127 S.Ct. 2197, 167 L.Ed.2d 1081 (2007); Reger Dev. LLC v. Nat'l City Bank, 592 F.3d 759, 763 (7th Cir.2010). Pursuant to Rule 8(a)(2), a complaint must contain "a `short and plain statement of the claim showing that the pleader is entitled to relief,' sufficient to provide the defendant with `fair notice' of the claim and its basis." Tamayo v. Blagojevich, 526 F.3d 1074, 1081 (7th Cir.2008) (quoting Fed.R.Civ.P. 8(a)(2) and Bell Atlantic Corp. v. Twombly, 550 U.S. 544, 555, 127 S.Ct. 1955, 167 L.Ed.2d 929 (2007)). Rule 8(a)(2) requires more than mere "labels and conclusions" or a "formulaic recitation of the elements of a cause of action." Twombly, 550 U.S. at 545, 127 S.Ct. 1955. "Detailed factual allegations" are not required, but the plaintiff must allege facts that, when "accepted as true ... state a claim to relief that is plausible on its face." Ashcroft v. Iqbal, 556 U.S. 662, 678, 129 S.Ct. 1937, 173 L.Ed.2d 868 (2009) (quoting Twombly, 550 U.S. at 570, 127 S.Ct. 1955) (internal quotation marks omitted). A claim has facial plausibility when its factual content allows the Court to draw a reasonable inference that the defendant is liable for the misconduct alleged. Id.
While the federal rules generally provide for liberal notice pleading, Rule 9(b) requires that plaintiffs averring fraud state "with particularity the circumstances constituting fraud." Fed.R.Civ.P. 9(b).
While the circumstances constituting fraud must be pleaded with particularity, a defendant's "[m]alice, intent, knowledge [or] other condition of mind ... may be averred generally." Fed.R.Civ.P. 9(b); see also DiLeo, 901 F.2d at 627. In the Seventh Circuit, a plaintiff who provides a "general outline of the fraud scheme" sufficient to "reasonably notify the defendants of their purported role" in the fraud satisfies Rule 9(b). Midwest Grinding Co. v. Spitz, 976 F.2d 1016, 1020 (7th Cir.1992). "[F]air notice is `[p]erhaps the most basic consideration' underlying Rule 9(b)." Vicom, Inc. v. Harbridge Merchant Servs., Inc., 20 F.3d 771, 777-78 (7th Cir.1994) (quoting 5 Wright & Miller, Federal Practice and Procedure § 1298, at 648 (1969)). Further, when details of the fraud itself "are within the defendant's exclusive knowledge," specificity requirements are less stringent. Jepson, Inc. v. Makita Corp., 34 F.3d 1321, 1328 (7th Cir.1994). Under those circumstances, the complaint must plead the grounds for the plaintiff's suspicions of fraud. Bankers Trust Co. v. Old Republic Ins. Co., 959 F.2d 677, 684 (7th Cir.1992).
The heightened pleading standard in fraud cases established by Rule 9(b) serves "three main purposes: (1) protecting a defendant's reputation from harm; (2) minimizing `strike suits' and `fishing expeditions'; and (3) providing notice of the claim to the adverse party." Vicom, 20 F.3d at 777; see also Ackerman, 172 F.3d at 469 (The purpose of Rule 9(b) is to "force the plaintiff to do more than the usual investigation before filing his complaint" in order to "assure that the charge of fraud is responsible and supported, rather than defamatory and extortionate."); Pirelli Armstrong Tire Corp. Retiree Med. Benefits Trust v. Walgreen Co., 631 F.3d 436, 441-42 (7th Cir.2011) (Rule 9(b)'s heightened pleading standard derives from "the potential stigmatic injury that comes with alleging fraud" and the desire to discourage a "sue first, ask questions later" approach to fraud litigation.). The Seventh Circuit has shied away from a rigid, formulaic approach to Rule 9(b) and noted that "[t]he twin demands of detail and flexibility, though in tension with one another, make sense in light of the competing purposes of the federal rules." Pirelli, 631 F.3d at 442.
A statute of limitations is an affirmative defense. Fed.R.Civ.P. 8(c)(1). Dismissing a claim as untimely at the pleading state is an "unusual step, since a complaint need not anticipate and overcome affirmative defenses, such as the statute of limitations." Cancer Found., Inc. v. Cerberus Capital Mgmt., LP, 559 F.3d 671, 674 (7th Cir.2009). "[A] federal complaint does not fail to state a claim simply because it omits facts that would
The False Claims Act and the IWRPA, in relevant parts, makes it unlawful to knowingly (1) present or cause to be presented to the United States government a false or fraudulent claim for payment, 31 U.S.C. § 3729(a)(1) (1994); 740 Ill. Comp. Stat. 175/3(a)(1)(A), or (2) make or use or cause to be made or used a false record or statement material to a false or fraudulent claim paid or approved by the United States government, 31 U.S.C. § 3729(a)(1)(B); 740 Ill. Comp. Stat. 175/3(a)(1)(B).
Defendants argue that Relators have failed to plead their fraud claims with the particularity required by Rule 9(b). (R. 170, MOR's & Drs.' Mem. at 10.)
Defendants allege that Relators improperly pleaded that Defendants submitted false Medicare claims upon information and belief. (R. 170, MOR's & Drs.' Mem. at 13, 18.) A plaintiff that pleads based on information and belief "is representing that he has a good-faith reason for believing what he is saying, but acknowledging that his allegations are based on secondhand information that he believes to be true." Pirelli, 631 F.3d at 442 (quoting Black's Law Dictionary 783 (7th ed. 1999)) (internal quotation marks omitted). Defendants contend that although Relators allege on information and belief that claims for overlapping surgeries were submitted to Medicare, they fail to specifically identify any such surgeries or claims. (R. 170, MOR's & Drs.' Mem. at 15.) A plaintiff may plead fraud based on information and belief if "(1) the facts constituting the fraud are not accessible to the plaintiff and (2) the plaintiff provides the grounds for his suspicions." Pirelli, 631 F.3d at 443 (internal quotation marks omitted). "The grounds for the plaintiff's suspicions must make the allegations plausible, even as courts remain sensitive to information asymmetries that may prevent a plaintiff from offering more detail." Id. Rule 9(b)'s requirements can be fulfilled by pleading facts on information and belief if they are "facts inaccessible to the plaintiff, in which event he ha[s] to plead the grounds for his suspicions." Bankers Trust, 959 F.2d at 684.
In the Complaint, Plaintiffs plead several paragraphs "on information and belief." (See, e.g., R. 168, Fourth Am. Compl. ¶¶ 91, 103, 109.) Each one of these paragraphs, however, alleges that specific claims were submitted to Medicare. Plaintiffs do not plead other allegations on information and belief. Whether claims were actually submitted to Medicare is information that is inaccessible to Relators. See Corley v. Rosewood Care Ctr., Inc., 142 F.3d 1041, 1051 (7th Cir.1998) ("[T]he particularity requirement of Rule 9(b) must be relaxed where the plaintiff lacks access to all facts necessary to detail his claim."). Relators state the "grounds for [their] suspicions" in pleading that fraudulent claims were submitted to Medicare consistent with the pattern and practices of the Doctor Defendants and of Rush. Bankers Trust, 959 F.2d at 684; see Uni*Quality, Inc. v. Infotronx, Inc., 974 F.2d 918, 923 (7th Cir.1992). Relators' inferences that such claims were submitted to Medicare, consistent with the pattern and practice for surgeries on Medicare-eligible patients by MOR doctors at Rush, are reasonable. See Aventis Pharm., 512 F.Supp.2d at 1167 ("Given the significant proportion of medical care in this country that is financed by Medicare and Medicaid, relators have drawn a reasonable inference that claims for reimbursement ... were submitted to the federal government or the State of Illinois for payment.").
Although the inferences are reasonable, Relators' allegations must meet
Here, Relators allege specific details about all but the submission of the claims, and they provide reasonable inferences that MOR and Doctor Defendants submitted false Medicare claims. They have pleaded on information and belief only facts about the submissions of the claim that are inaccessible to them, and they have stated reasonable grounds for their suspicions. See Aventis Pharm., 512 F.Supp.2d at 1167 (holding that relators had alleged the facts they could with particularity and had drawn reasonable inferences that the claims were actually submitted to the government. "For these reasons, dismissal at this stage under Rule 9(b) would be inappropriate."). The Court declines to dismiss the Complaint on the grounds that some paragraphs were pleaded on information and belief.
Defendants next argue that Relators' allegations fall short of the Rule 9(b) pleading standard because they fail to answer the "who, what, where, when, and how" "newspaper questions" set out in DiLeo. (R. 170, MOR's & Drs.' Mem. at 13-14.) Defendants argue that Relators' Complaint "include[s] only conclusory and unsupported allegations that there was any actual overlap in the surgeries and fail[s] to provide any details of the actual times at which the surgeries and their component parts took place." (Id. at 13.) Specifically, Defendants contend that Relators fail to specify the surgeries, and the dates and locations of the surgeries, for which fraudulent Medicare claims were submitted. (Id. at 13-15.) Additionally, Defendants argue that Relators' allegations do not identify any wrongful conduct. (Id. at 13.) Defendants claim that because the Medicare Rules and Regulations specifically contemplate overlapping surgeries, allegations that MOR and Doctor Defendants conducted overlapping surgeries are not sufficient to state a claim. (Id. at 13-17.)
The Complaint clearly sets out the Doctor Defendants and MOR as the entities and individuals who submitted the false claims. (See, e.g., R. 168, Fourth Am. Compl. ¶¶ 67-69, 86, 99, 103, 108, 116.) Relators contend that to the extent Defendants seek identification of the patients, the Complaint omitted the specific patient names to protect confidentiality, and that "numerous patients" are identified in the Complaint who are Medicare-eligible and had surgeries that overlapped with other patients. (R. 173, Relators' Resp. at 9) (citing R. 168, Fourth Am. Compl. at ¶¶ 87, 97, 105, 112, 129, 137, and 145). Defendants' argument that because all Medicare-eligible patients do not rely on Medicare, and therefore Medicare-eligibility is not an accurate proxy for specific patients, misses the mark: the purpose of the "who" question is to make sure the defendants know what claims are being brought against them. See, e.g., United States ex rel. Garst v. Lockheed-Martin Corp., 328 F.3d 374, 376 (7th Cir.2003) (the complaint needed to "state who made the [false] statement to whom and when"); Vicom, 20 F.3d at 778 (the complaint should inform
Defendants argue that Relators do not plead the requisite details of Defendants' acts of fraud. (R. 170, MOR's & Drs.' Mem. at 13.) For example, Defendants contend that "[r]ather than identifying specific Medicare surgeries or claims, Relators focus their allegations on the respective surgery schedules of the defendant physicians, without specifically identifying the Medicare procedures that were performed or the claims that were allegedly submitted to Medicare." (Id. at 12). Defendants' arguments are inaccurate. As an example, paragraph 84 of the Complaint alleges that "on September 13, 1996, MO surgeon Dr. George Holmes, Jr. was scheduled to perform an orthopedic operation on Mr. H.'s leg amputation stump," and paragraph 85 alleges that "Mr. H[.]'s procedures were covered under Medicare." The former paragraph appears to specifically identify the Medicare procedure that was performed (as well as who performed it when), and the latter paragraph identifies the accompanying Medicare claim.
Defendants contend that "the Medicare Rules specifically contemplate the performance of overlapping surgeries." (Id. at 13.) They argue that, without alleging the durations of the surgeries, Relators fail to provide sufficient information to infer that the surgeries even overlapped, let alone that claims for overlapping surgeries constitute fraud. (R. 175, MOR's & Drs.' Reply at 12.) The specific wrongdoing the Complaint alleges consists of more than just overlapping surgeries, which alone is not a Medicare violation. See 2002 Rules § 15016(C)(4)(a)(2). Rather, the Complaint alleges that MOR and Doctor Defendants:
(R. 168, Fourth Am. Compl. ¶ 44.) Assuming the truth of these allegations, which the Court must on a motion to dismiss, these practices appear to violate the Medicare Rules and Regulations. Although the Medicare Rules and Regulations contemplate the performance of overlapping surgeries, the teaching physician must ensure that another surgeon is immediately available. 2002 Rules § 15016(C)(4)(a)(2). The Teaching Physician Regulations specify that a payment for teaching physicians is made only if the teaching surgeon is present or immediately-available during the entire procedure. 42 C.F.R. § 415.172(a)(1). The fraud Relators allege consists of submitting Medicare claims for overlapping surgeries in which the teaching physician was not immediately available and did not arrange for another surgeon to be immediately available to assist. Such allegations satisfy the "what" inquiry.
Defendants argue that Relators fail to allege the locations at which the surgeries that were billed to Medicare were performed and "the places from which or to which such misrepresentations were submitted or made." (R. 170, MOR's & Drs.' Mem. at 14.) The Complaint specifies
Defendants argue that Relators fail to provide any dates relevant to their fraud with sufficient specificity. (R. 170, MOR's & Drs.' Mem. at 14.) The Complaint provides specific examples of the alleged fraud that occurred on specific dates in 1996, 2004, and 2005, (e.g., R. 168, Fourth Am. Compl. ¶¶ 84, 87, 137), and alleges that Dr. Goldberg voiced his concerns about the fraud to senior Rush officers repeatedly between 1999 and 2004, (id. ¶ 55). Relators have therefore alleged when the fraud occurred with sufficient specificity to satisfy Rule 9(b). See Upton, 900 F.Supp.2d at 828-29.
With respect to how Defendants allegedly implemented the fraudulent scheme, Relators allege that Doctor Defendants conducted overlapping surgeries without designating a back-up surgeon, (R. 168, Fourth Am. Compl. ¶ 44); that Rush failed to document Doctor Defendants' entry and exit times, (id. ¶ 76); and that Defendants submitted claims to Medicare for the overlapping surgeries that they knew did not comply with Medicare Rules, (id. ¶ 51). Defendants argue that Relators' allegations "fail to specifically identify any surgeries that actually overlap." (R. 170, MOR's & Drs.' Mem. at 15.) At this stage, concrete evidence that the surgeries actually overlapped is inaccessible to Relators, but the surgery schedules and Relators' allegations about the distance between operating rooms allow the Court to easily infer that surgeries did overlap.
Defendants would have the Court believe that it will be alone in relaxing Rule 9(b) if it allows Relators' Complaint to proceed. (R. 175, MOR's & Drs.' Reply at 16.) The Court is not venturing into unknown territory, however, by applying Seventh Circuit precedent instructing that a complaint satisfies Rule 9(b) by providing the general outline of a fraudulent scheme and detailed representative examples. See, e.g., Upton, 900 F.Supp.2d at 828-30 (holding that the complaint, taken as a whole, plausibly alleged a fraudulent scheme by way of alleging several instances of the fraud); Mason, 731 F.Supp.2d at 735 (holding that an outline of the fraudulent scheme identifying the persons involved, relevant timeframes, and manner of fraud, in addition to concrete examples, satisfied "the substance and purpose of Rule 9(b)"); United States ex rel. Gear v. Emergency Med. Assocs. of Ill., No. 00 C 1046, 2004 WL 1433601 (N.D.Ill. June 25, 2004) (holding that the complaint, which identified the particular persons and locations involved and "the specific regulations which were allegedly violated," provided "adequate notice of the specific activities constituting the alleged fraud, thereby placing [defendant] in position to file an effective responsive pleading. This is all Rule 9(b) requires."); United States v. Cancer Treatment Centers of Am., No. 99 C 8287, 2003 WL 21504998, at *1-*2 (N.D.Ill. June 30, 2003) (holding that although the complaint frequently did "not give specific names or dates," it outlined a general fraudulent scheme and there was "enough information in the complaint to allow defendants to respond and prepare a defense"); United States ex rel. Bidani v. Lewis, No, 97 C 6502, 1998 WL 1820753, at *10 (N.D.Ill.Dec. 29, 1998) (holding that the complaint lacked some details but that it satisfied Rule 9(b) by generally alleging
Although Relators do not fully detail all the circumstances of the alleged misrepresentations in their Complaint, the Court finds that they sufficiently allege fraud for the purposes of Rule 9(b), thereby giving MOR and Doctor Defendants sufficient notice to prepare a defense against the claim. Relators' allegations do not vaguely refer to unidentifiable transactions and misrepresentations. Rather, Relators allege that MOR and Doctor Defendants made a consistent practice of filing claims for Medicare reimbursement that did not satisfy Medicare's standards. The Complaint pleads specific details, including surgery schedules, that detail noncompliance with Medicare Rules and Regulations. Defendants argue that some of Relators' allegations are untrue and unsupported by specific details. (R. 170, MOR's & Drs.' Mem. at 15 n. 9.) At this stage in the litigation, however, all of Relators' allegations are presumed true and all reasonable inferences must be drawn in their favor. Reger Dev., 592 F.3d at 763. Although Relators do not identify the particular individual who submitted the Medicare claims, or the precise time, place, and method of each submission, the Court accepts Relators' assertions that these details are in Defendants' sole possession and are inaccessible to them. See Luckey v. Baxter Healthcare Corp., 95 C 509, 1996 WL 242977, at *9 (N.D.Ill. May 9, 1996) (holding that the complaint satisfied Rule 9(b) when it alleged that defendant made repeated representations, the content of those representations, and the grounds for alleging that the representations were fraudulent, even though it did not identify "the particular individual who communicated the guarantees, and the precise time, place, and method of each communication"). The Court concludes that the Complaint complies with Rule 9(b) by pleading a general fraudulent scheme, identifying the individual defendants and their roles within the scheme, pleading specific representative examples that answer all five of the "newspaper questions," and providing reasonable grounds for suspicion of the facts that are inaccessible to Relators. See DiLeo, 901 F.2d at 627; Bankers Trust, 959 F.2d at 684.
MOR and Doctor Defendants argue that Relators' Complaint should be dismissed pursuant to Rule 12(b)(6) for failure to state a claim under the FCA and the IWRPA because Relators do not allege any specific fraudulent claim that was submitted to either the United States or the State of Illinois. (R. 170, MOR's & Drs.' Mem. at 18, 20.) MOR and Doctor Defendants argue that Relators have failed to provide any link between specific allegations of deceit and claims that were submitted to the government. (Id. at 18.) Although MOR and Doctor Defendants label this a Rule 12(b)(6) argument, it is in substance an argument about the sufficiency of Relators' Complaint, which was thoroughly addressed above.
MOR and Doctor Defendants argue that they never violated the FCA and claim that Relators "attempted to manufacture a non-existent inference of wrongful conduct," which is "belied by the fact that the Medicare Rules and Regulations expressly permit the performance of overlapping surgeries." (Id. at 16.) MOR and Doctor Defendants argue that the Medicare Rules and Regulations do not require documentation of a teaching physician's entry and
The Medicare Rules and Regulations specifically provide that "the medical records must document the teaching physician was present at the time the service is furnished. The presence of the teaching physician during procedures may be demonstrated by the notes in the medical records made by a physician, resident, or nurse." 42 C.F.R. § 415.172(b). The 1996 Rules specifically instruct that in the case of two overlapping surgeries, the teaching surgeon "must personally document the key portion of both procedures in his or her notes in order that a reviewer may clearly infer that the teaching physician was immediately available to return to either procedure in the event of complications." 1996 Rules § 15016(C) (3)(a)(2). The 2002 Rules further clarify that the "documentation must identify, at a minimum, the service furnished, the participation of the teaching physician in providing the service, and whether the teaching physician was physically present." 2002 Rules § 15016(A)(8).
Finally, MOR and Doctor Defendants argue that the Medicare Rules and Regulations allow a teaching physician to be involved in another surgery as long as it is one from which she may return and that the Medicare Rules and Regulations require teaching physicians to arrange for an immediately available replacement only when the need arises, not every time surgeries overlap. (R. 170, MOR's & Drs.' Mem. at 17.) Relators argue that a teaching physician must always arrange for an immediately available replacement if they will not be available during part of the procedure. (R. 173, Relators' Resp. at 3.)
The Medicare Rules and Regulations instruct that "[i]f the teaching physician leaves the operating room ... to become involved in another surgical procedure, he or she must arrange for another physician to be immediately available to intervene in the original case should the need arise in order to bill for the original procedure." 1996 Rules § 15016(C)(3)(a). This language does not, as MOR and Doctor Defendants suggest, mean that teaching physicians must find a replacement only when the need arises. If the Medicare Rules and Regulations were given the meaning MOR and Doctor Defendants suggest, residents left alone in an operating room and faced with an emergency would be aided by a teaching physician only after someone had run into the second operating room, having taken the requisite time to become properly sterilized; the runner had informed the teaching physician of the situation; the teaching physician had considered what other qualified physicians were available at the time and selected one; and the replacement doctor had been informed that her presence was requested in the first operating room. Such an interpretation contradicts the purpose of having arranged for a back-up in advance. As Relators explain "`should the need arise' is an explanation of why you need to arrange for a back-up — not when you should arrange for it." (R. 173, Relators' Reply at 8.) The 1996 Rules support this reading: "If the teaching physician leaves the operating room after the key portion(s) of the surgical procedure or during the closing of the surgical field to become involved in another surgical procedure, he or she must arrange for another physician to be immediately available to intervene in the original case should the need arise in order to bill for the original procedure." 1996 Rules § 15016 (C) (3)(a).
Accordingly, Relators' allegations that MOR and Doctor Defendants scheduled concurrent surgeries without arranging for another surgeon to be immediately available, failed to adequately and accurately document their presence and absence
Like MOR and Doctor Defendants, Rush argues that Relators fail to state a claim for violation of the FCA or the IWRPA and moves to dismiss the Complaint pursuant to Rule 12(b)(6). (R. 172, Rush's Mem. at 14.) Rush argues that Relators improperly attempt to bootstrap their claims against Rush by standard of care allegations. (Id. at 18-19.) Rush contends that its claims to the government are for reimbursement for the use of its facilities and the cost of educating residents. (Id. at 14.) The Teaching Physician Rule, which undergirds Relators' claims, has no application to facility fee payments to hospitals. See 42 C.F.R. § 415.172. Nor, Rush contends, is there any regulation that requires Rush to certify compliance with the Teaching Physician Rule. (R. 172, Rush's Mem. at 14.) Rush argues that Relators' claims against them amount to nothing more than standard of care claims, which the FCA is not intended to address. (Id. at 16-17.)
Relators agree that the Teaching Physician Rule is "directed in the first instance towards doctor billing," but argues that Rush is still liable for "seek[ing] reimbursement for "surgeries that it knows do not comply with Medicare rules." (R. 173, Relators' Resp. at 18.) Relators allege that Rush was not a passive beneficiary of MOR's and the Doctor Defendants' fraud, but rather a willing participant. (R. 168, Fourth Am. Compl. ¶ 58.)
The closest Relators come to stating a claim against Rush under the FCA is their allegation that "[i]t was the job of Rush orthopedic nurses to facilitate the Doctor Defendants' practice of conducting surgeries simultaneously in two operating rooms." (Id. ¶ 75.) Even if this allegation imported any vicarious liability to Rush, however, Relators go on to negate Rush's control by alleging that "[e]ven when the Rush nurses who worked with the Doctor Defendants were instructed by their supervisors to record teaching physician times in and out of their surgeries, they refused to do so." (Id. ¶ 79.) Additionally, Relators do not allege that Rush submitted any false claims to the government. Relators' allegations are based upon the Medicare Part B requirements for the reimbursement of teaching physicians, (id. ¶ 36), while RUMC and SurgiCenter, as hospitals, are reimbursed for the use of their facilities under Medicare Part A, (id. ¶ 14).
The Complaint adequately alleges that MOR and Doctor Defendants knowingly violated the Medicare Rules and Regulations requiring teaching physicians to be immediately available during surgeries and that they submitted claims for reimbursement as though they had complied with the Medicare Rules. The Complaint fails to allege any fraudulent claims submitted by Rush or under Medicare Part A, or any requirements for reimbursement under Medicare Part A that Rush knowingly failed to meet. Permitting Doctors to schedule concurrent surgeries is not grounds for a cause of action under the Act. Accordingly, the Court finds that Relators have failed to state a claim under the Act against Rush. Counts III and IV of the Complaint are therefore dismissed pursuant to Rule 12(b)(6).
In Count V, Relators allege that each Defendant conspired to commit the
The allegations of conspiracy within the Complaint lack the requisite particularity to satisfy Rule 9(b). Relators argue that they "have alleged concrete facts from which, at minimum, a reasonable inference can be drawn that Rush and the Doctor Defendants entered into an unlawful conspiracy" to submit fraudulent Medicare claims. (R. 173, Relators' Resp. at 15.) However, Relators make only conclusory allegations about any agreement or conspiracy among Defendants. (See, e.g., R. 168, Fourth Am. Compl. ¶¶ 52, 58, 67, 78.) Unlike the fraudulent scheme alleged in Counts I and II, for which Relators provide detailed representative examples, Relators fail to describe a single instance of discussion, agreement, or conspiracy among Defendants. The Complaint may allege who conspired, but it fails to allege with any specificity what they conspired to do, when, where, or how. See Garst v. Lockheed Integrated Solutions Co., 158 F.Supp.2d 816, 824 (N.D.Ill.2001) (holding that general allegations that left the court "to speculate at who was involved in this supposed conspiracy" did not survive a motion to dismiss). Accordingly, Count V is dismissed.
Finally, Drs. Berger, Rosenberg, and Sheinkop allege that any claims against them are barred as a matter of law based upon the applicable statutes of limitations. (R. 170, MOR's & Drs.' Mem. at 6.) A civil action under the FCA may not be brought:
31 U.S.C. § 3731(b). The IWRPA contains a nearly identical statute of limitations. 740 Ill. Comp. Stat. 175/5(b). Defendants argue that the tolling provision in 31 U.S.C. § 3731(b)(2) only applies when the government intervenes and that only the six-year limitations period in 31 U.S.C. § 3731(b)(1) is applicable to qui tam actions in which the government has not intervened. (R. 170, MOR's & Drs.' Mem. at 7-8.) Accordingly, Defendants contend that claims against Drs. Berger, Rosenberg, and Sheinkop should be dismissed because all three were first named as defendants in the third amended complaint, filed on June 21, 2010, and all of the claims against them occurred prior to June 21, 2004. (Id. at 9.)
Relators argue that the tolling provision applies to their claims but concede that their claims against the individual doctors who were named for the first time in the third amended complaint are subject to a six-year limitation because 31 U.S.C. § 3731(b)(1) provides the longer period of time. (R. 173, Relators' Resp. at 25) (invoking the "whichever occurs last" language of the statute). Relators argue that the six-year limit does not bar their claims against Drs. Berger, Rosenberg, and Sheinkop, however, because the specific dated incidents in the Complaint are only representative examples of misconduct, and all Defendants continued to participate in the fraudulent scheme after June 21, 2004. (Id. at 21.) Relators further argue that the Complaint is "not required to plead around a statute of limitations affirmative defense," and thus the fact that the Complaint does not happen to include allegations of specific incidents of fraud that Drs. Berger, Rosenberg, and Sheinkop committed after June 21, 2004 does not subject the claims against them to dismissal. (Id.) (citing Xechem, Inc. v. Bristol-Myers Squibb Co., 372 F.3d 899, 901 (7th Cir.2004)). "[A] plaintiff is not required to plead facts in the complaint to anticipate and defeat affirmative defenses." Indep. Trust Corp. v. Stewart Info. Servs. Corp., 665 F.3d 930, 935 (7th Cir. 2012). The Court agrees with Relators that "[t]he inclusion of the specific examples set forth in ¶¶ 84-152 in no way limit[s] Relators' claims only to those instances." (R. 173, Relators' Resp. at 21); see
For the foregoing reasons, the Court DENIES in part and GRANTS in part Defendants' Motions to Dismiss (R. 169, R. 171). Counts III, IV, and V of the Fourth Amended Complaint are dismissed, and defendants Rush University Medical Center and Rush SurgiCenter Limited Partnership are dismissed from the case. Counts I and II asserted against Midwest Orthopaedics at Rush, LLC and the individual Doctor Defendants remain. The remaining parties are directed to exhaust all settlement possibilities prior to this Court's next status hearing on April 2, 2013, at which time this Court will set an expedited litigation schedule for this delayed lawsuit.