United States Ex Rel. Groat v. Boston Heart Diagnostics Corp.
255 F. Supp. 3d 13
| D.D.C. | 2017Background
- Relator Tina D. Groat, M.D., a UnitedHealthcare medical director, brought a qui tam action under the federal False Claims Act (FCA) and multiple state analogues against Boston Heart Diagnostics, a clinical laboratory, alleging it billed government payors for medically unnecessary cardiac-related genetic and non‑genetic tests.
- Alleged scheme: Boston Heart supplied pre‑printed test requisition forms and marketing materials (including test panels) that encouraged non‑cardiology physicians to order grouped tests, increasing billing for tests used as screening rather than for medically necessary diagnostic care.
- Relator relied on UnitedHealthcare claims data (2013) showing Boston Heart as an outlier in ordering a seven‑test combination and identified specific claims submitted to United for Medicare/Medicaid patients with four diagnostic codes (routine exam, hypertension, hyperlipidemia, malaise/fatigue).
- Key legal theory: Boston Heart submitted legally false claims by certifying medical necessity on CMS‑1500 forms while allegedly billing for screening tests not covered by Medicare/Medicaid; relator pleaded express and implied false certification and false statements under 31 U.S.C. § 3729(a)(1)(A) and (B).
- Procedural posture: United and states declined to intervene; relator filed a Second Amended Complaint; Boston Heart moved to dismiss under Rules 9(b) and 12(b)(6); the court granted judicial notice of certain CMS coverage materials, denied dismissal of most federal FCA presentment/false‑statement claims, but dismissed the reverse‑false‑claims count and claims on behalf of Maryland.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether relator pleaded submission of claims to government with Rule 9(b) particularity | Groat relied on United data showing Boston Heart submitted >$369,000 in claims to United for the challenged tests for Medicare/Medicaid patients and provided representative claim examples | Boston Heart said relator failed to identify specific submitted government claims, amounts, or individuals | Court: pleaded sufficiently — representative data and a concrete example meet Rule 9(b) in this context |
| Whether claims were false (factual or legal falsity; medical necessity) | Groat alleged tests were not medically necessary for patients with the four diagnostic codes, citing guidelines and coverage determinations; billing certified necessity on CMS‑1500 | Boston Heart argued labs must rely on ordering physicians; differences in clinical judgment make falsity implausible | Court: legal falsity adequately pleaded — laboratories certify medical necessity and bear burden to establish it; factual disputes on medical necessity inappropriate to resolve at motion to dismiss |
| Whether defendant acted with requisite knowledge (scienter) | Groat alleged corporate scheme, targeted marketing, test panels, and a meeting where relator informed Boston Heart tests were unnecessary; scienter may be pled generally under Rule 9(b) | Boston Heart argued no particular individual knowledge pleaded and no duty to question physicians | Court: scienter adequately alleged at corporate level; Rule 9(b) permits general averment of knowledge |
| Whether reverse false claims (31 U.S.C. § 3729(a)(1)(G)) pleaded | Groat argued overpayments/obligations to repay arise from fraudulent claims and thus sustain a reverse‑false‑claim count | Boston Heart argued relator alleged no independent preexisting obligation to pay or repay absent concealment; such a theory would convert every FCA claim into reverse claim liability | Court: dismissed Count II — relator failed to plead an independent obligation under § 3729(a)(1)(G); analogous state reverse‑claim counts dismissed; Maryland claims previously dismissed |
Key Cases Cited
- Ashcroft v. Iqbal, 556 U.S. 662 (standards for pleading plausibility)
- Bell Atl. Corp. v. Twombly, 550 U.S. 544 (pleading requirement of plausibility)
- United States ex rel. Heath v. AT & T, Inc., 791 F.3d 112 (D.C. Cir. 2015) (Rule 9(b) does not require representative samples of claims; corporate‑level fraud pleading)
- United States v. Sci. Applications Int’l Corp., 626 F.3d 1257 (false certification framework: express and implied)
- Universal Health Servs., Inc. v. United States, 136 S. Ct. 1989 (materiality requirement for FCA implied‑certification claims)
- United States v. Kellogg Brown & Root Servs., Inc., 800 F. Supp. 2d 143 (distinguishing factual vs. legal falsity)
- United States ex rel. Merena v. SmithKline Beecham Corp., 205 F.3d 97 (laboratory billing schemes and FCA liability)
- United States v. Honeywell Int’l, Inc., 798 F. Supp. 2d 12 (knowledge may be alleged generally under Rule 9(b))