United States of America v. Adventist Health System/SunBelt Inc.
6:10-cv-01062
| M.D. Fla. | Jul 30, 2012Background
- Defendant operates several central Florida hospitals; Relators Dittmann and Elenberger are former FRA employees with relevant insider knowledge.
- Relators allege three FCA/Florida FCA violations: improper use of billing code modifiers to bypass edits, overbilling by charging for a 5000mcg Octreotide dose when 1000mcg was used, and billing CAD analysis when CAD was not used.
- Defendant moved to dismiss for failure to state a claim and Rule 9(b) pleading deficiencies.
- Court applied Rule 8 and 9(b) standards, requiring plausible claims and particularity for fraud, including time, place, and specifics of fraudulent acts.
- Court found the First Amended Complaint provides extensive, particularized facts with personal knowledge and contemporaneous discussions, satisfying Rule 9(b).
- Conclusion: Motion to Dismiss denied; ruling issued July 30, 2012.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Does the FCA pleading meet Rule 9(b) particularity? | Dittmann and Elenberger provide time, place, and specifics. | Relators fail to plead with requisite particularity. | Yes, claims satisfy Rule 9(b). |
| Are the three alleged schemes sufficiently described? | Relators detail modifiers, dose misbilling, and CAD billing with supporting facts. | Allegations lack specificity for each scheme. | Sufficient detail for all three schemes. |
| Do relators' personal knowledge and inside involvement give indicia of reliability? | Relators were billing/coding personnel with firsthand observations and meetings. | Relators are not insiders; reliability uncertain. | Indicia of reliability established; claims survive. |
| Is the Florida FCA claim viable given no State intervention? | State intervenor status does not bar proceedings; consent not required here. | No consent to pursue Florida FCA claim. | No merit; State intervention issue resolved inRelators' favor. |
Key Cases Cited
- United States ex rel. Walker v. R&F Properties of Lake County, Inc., 433 F.3d 1349 (11th Cir. 2005) (false claims can arise from non-reimbursable or misrendered services)
- United States ex rel. Clausen v. Lab. Corp. of Am., Inc., 290 F.3d 1301 (11th Cir. 2002) (Rule 9(b) pleading requirements apply to FCA actions)
- United States ex rel. Atkins v. McInteer, 470 F.3d 1350 (11th Cir. 2006) (insiders' personal knowledge supports reliability in qui tam)