J. Michael Mastej v. Health Management Associates, Inc., 591 F. App'x 693

Relator Michael Mastej (longtime HMA executive) filed a qui tam FCA suit against Health Management Associates, Inc. and Naples HMA, alleging pay-for-referral schemes (six neurosurgeons paid for "on-call" coverage and a 2008 golf-trip benefit for four physicians) that induced Medicare referrals; defendants submitted interim Medicare claims and annual hospital cost reports including certifications of legal compliance.
Mastej alleges the schemes violated Stark and Anti‑kickback statutes and therefore rendered claims and year‑end certifications false under the False Claims Act (pre‑2009 text relied on in his complaint).
Complaint identified specific doctors, amounts, dates of the incentives, and internal actors; it did not identify any individual Medicare claim forms, patient names, dates/amounts of billed claims, or which specific referrals resulted in submitted claims.
District court dismissed for failure to plead fraud with particularity under Fed. R. Civ. P. 9(b). Mastej appealed.
On appeal, the Eleventh Circuit held that (1) Mastej’s detailed allegations and his first‑hand knowledge as HMA VP and a hospital CEO provided sufficient indicia of reliability to plead false claims for the 2007 period while he was employed, and (2) his generalized allegations were inadequate for claims after he left in October 2007 (2008–2009).

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether Rule 9(b) is satisfied as to submission/payment of false Medicare interim claims and related cost‑report certifications	Mastej: detailed scheme allegations + his employment experience suffice to show actual claims were submitted and paid	Defendants: complaint lacks particularity—no patient names, claim dates, amounts, or representative claims showing submission/payment	Court: Rule 9(b) satisfied for 2007 (when Mastej had first‑hand access); not satisfied for 2008–2009 after he left employment
Whether hospital cost reports and certifications can be pleaded as false without alleging specific patient claims	Mastej: year‑end cost reports aggregate interim claims and thus necessarily included improper referrals, making certifications false	Defendants: without patient‑specific interim claims, cost‑report certifications are conjectural	Held: 2007 cost report adequately pleaded (it necessarily encompassed 2007 interim claims); later years not adequately pleaded
Effect of 2009 FCA amendment on make‑or‑use claim (whether proof of payment required)	Mastej: contends the 2009 amendment removes the payment element for make‑or‑use claims	Defendants: note that complaint tracks pre‑2009 statute and alleged payment is an element	Held: Court need not resolve change; plaintiff pleaded under pre‑2009 text and cannot invoke amendment mid‑litigation; even under new text, result would be same (pleading adequate only for 2007)

United States ex rel. Clausen v. Lab. Corp. of Am., Inc., 290 F.3d 1301 (11th Cir.) (Rule 9(b) requires indicia of reliability beyond schematic allegations)
Hopper v. Solvay Pharm., Inc., 588 F.3d 1318 (11th Cir.) (representative claims/billing data can satisfy Rule 9(b); improper practices alone insufficient)
United States ex rel. Walker v. R&F Props. of Lake Cty., 433 F.3d 1349 (11th Cir.) (relator’s first‑hand employment knowledge can supply indicia of reliability)
United States ex rel. Atkins v. McInteer, 470 F.3d 1350 (11th Cir.) (Rule 9(b) particularity requirements in FCA context)
United States ex rel. Matheny v. Medco Health Solutions Inc., 671 F.3d 1217 (11th Cir.) (elements for pleading submission of a false claim)
Corsello v. Lincare, Inc., 428 F.3d 1008 (11th Cir.) (relator must explain basis for belief that fraudulent claims were submitted)
United States v. Vernon, 723 F.3d 1234 (11th Cir.) (elements of Anti‑kickback statute violation)