Delia Bell v. Karl E. Cross
21-11064
| 11th Cir. | Nov 26, 2021Background
- Relator Delia Bell, a registered nurse and former administrator at Cross Garden Care Center (CGCC), sued CGCC and owner Karl Cross under the False Claims Act alleging unnecessary therapy, inflated RUG scores, improper non‑discharges and readmissions to obtain Medicare reimbursements.
- SNF Medicare reimbursement is per diem and tied to patients’ RUG scores, which are derived from MDS assessments; higher RUG scores yield higher payments.
- Bell testified she was not a licensed therapist, did not prepare MDS or billing, never saw bills or MDS reports, and could not identify specific patients whose RUGs were improperly changed; she recalled emails from Cross about raising RUGs.
- Bell sought partial summary judgment and attached a declaration identifying seven patients she said were overtreated and claiming Cross instructed her to raise a RUG score; defendants moved for summary judgment and to strike the declaration as a sham.
- The district court denied Bell’s motion, granted defendants’ summary judgment (finding no genuine issue of material fact on false claims), and denied the motion to strike as moot; the Eleventh Circuit affirmed.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether the district court shifted the summary judgment burden to Bell | Bell: court improperly required her to prove absence of defendants’ showing; defendants should bear burden | Defendants: they carried initial burden and Bell then had to produce specific facts raising a genuine issue | Court: No improper shift; standard applied correctly — movant showed absence of dispute, burden shifted to nonmovant |
| Whether defendants submitted objectively false claims (falsity element of the FCA) | Bell: therapy was unnecessary, RUGs were inflated, and claims therefore false based on her declaration identifying seven patients | Defendants: clinical judgments were supported by professionals and Bell lacks medical/billing expertise and supporting expert proof of objective falsity | Court: Bell failed to raise a genuine dispute; her lay disagreement with therapy decisions and lack of qualified evidence or billing/MDS links is insufficient to prove objective falsity |
| Whether Bell’s declaration was a sham and should be stricken | Bell: declaration refreshed her recollection and identifies specific instances | Defendants: declaration contradicts deposition and is inadmissible | Court: Did not need to resolve sham issue because even considering the declaration, Bell failed to create a genuine issue of material fact; defendants prevail |
Key Cases Cited
- Ruckh v. Salus Rehab., LLC, 963 F.3d 1089 (11th Cir. 2020) (explains RUG scores and MDS assessments in SNF Medicare reimbursement)
- United States v. R&F Props. of Lake Cty., Inc., 433 F.3d 1349 (11th Cir. 2005) (sets out FCA elements)
- Jurich v. Compass Marine, Inc., 764 F.3d 1302 (11th Cir. 2014) (standard of review for summary judgment)
- Dietz v. Smithkline Beecham Corp., 598 F.3d 812 (11th Cir. 2010) (summary judgment burden-shifting framework)
- United States v. AseraCare, Inc., 938 F.3d 1278 (11th Cir. 2019) (requires objective falsity for clinical judgments under the FCA; expert evidence often necessary)
- United States ex rel. Clausen v. Lab'y Corp. of Am., 290 F.3d 1301 (11th Cir. 2002) (importance of medical and billing evidence in FCA cases alleging unnecessary services)