United States ex rel. Ciaschini v. Ahold USA Inc.
United States ex rel. Ciaschini v. Ahold USA Inc.
Opinion of the Court
MEMORANDUM
I. Introduction
Plaintiff/Relator David Ciaschini (“Ciaschi-ni”) brings suit under the qui tam provisions of the federal False Claims Act (“FCA”) against Defendants asserting violations of the FCA and similar state acts in Massachusetts, New York, Virginia, New Jersey, New Hampshire, Delaware, and the District of Columbia. Presently at issue is Defendants’ Motion to Dismiss Counts I, III and V through XI of the Amended Complaint [# 45]. For the following reasons, Defendant’s Motion to Dismiss is ALLOWED.
A. The False Claims Act
A private individual may bring a civil action for violations of the federal False Claims Act in the name of the United States.
In 2009, Congress passed the Fraud Enforcement Recovery Act of 2009 (“FERA”).
B. Factual Background
Relator Ciaschini is a licensed pharmacist in the Commonwealth of Massachusetts.
In 2007 and 2008, Joe Angileri, a Regional Pharmacy Manager for Stop & Shop and Ciaschini’s direct manager, instructed Cias-chini to audit nine of Stop & Shop’s Massachusetts stores.
Upon information and belief, as the defendants’ employees had apparently been directed by their regional supervisors, each time one of the defendants’ employees provided a Beneficiary with a shorted amount, the defendants’ employees: (a) entered into their pharmacy computer a false number of tablets, capsules or other items being dispensed, that being the full amount of the item called for in the prescription as opposed to the actual amount being dispensed, (b) printed out a receipt which falsely reflected that the Beneficiary had, in fact, received the full amount of the prescription, and (c) required the Beneficiary to sign an electronic signature capture pad, which recorded the Beneficiary’s signature as an acknowledgment, by the beneficiary, that they received the full amount of the prescription, despite the fact that they had not.20
According to Ciaschini, shorting bills submitted to Medicare and Medicaid constitute false claims.
To the extent that the defendants billed the government, in advance, for prescription medications and items before they were ever dispensed to a Beneficiary, but were eventually dispensed to a Beneficiary, the defendants fraudulently engaged in front-loading, thereby depriving the government of the use of such monies which the defendants had obtained in advance by false pretenses.22
In the Verified Amended Complaint, Ciaschini includes details regarding twenty instances of shorting. In each ease, he provides (1) the date Stop & Shop billed Medicaid, Medicare, or Masshealth; (2) the prescription number; (3) the initials of the customer beneficiary; (4) the number of tablets called for in the prescription; (5) the retail price of the prescription; (6) the date Stop & Shop partially dispensed the prescription; (7) the number of tablets initially dispensed; (8) a statement that Stop & Shop’s employees knowingly submitted a claim for the full prescription even though they only partially dispensed the prescription; (9) and a statement that the false claim did not indicate to Medicaid, Medicare, or Masshealth that Stop & Shop only partially dispensed the prescription.
The second process Ciaschini included in his audit report is referred to as “re-adjudi-eation.”
required to ‘re-adjudicate’ the approval for, and payment of, the Restocked Item through the electronic billing system for Federal Health Care Programs and have its account debited ... effectively refunding the payment which was received for the item approved but never picked up by or delivered to the Beneficiary.26
The third process is referred to as “lot control.” As the Verified Amended Complaint states: “Under federal law, manufacturers of prescription drugs are required to identify such products by ‘lot numbers’ with each lot having a specific expiration date.”
In each of his audit reports, Ciaschini included the following statement: “Illegal Billings. Can get fined.”
Ciaschini then filed his complaint in the current action. In his Verified Amended Complaint, he named Ahold USA Inc. (“Ahold”), The Stop & Shop Supermarket Company LLC, Giant Food LLC (“Giant”), Giant of Maryland LLC (“Giant MD”), and Stop & Shop/Giant-Landover (“Landover”) as defendants.
Defendant also alleges that Landover maintains one corporate headquarters with one main computer system that monitors prescription inventories at all Stop & Shop, Giant, and Giant MD stores.
In the Verified Amended Complaint, Cias-chini asserts that shorting (or front-loading), re-adjudication, and the mixing of lots violate the federal False Claims Act (Count I). In paragraphs 267-269, he specifically claims that Defendants violated 31 U.S.C. § 3729(a)(l)-(3).
C. Procedural Background
Relator Ciaschini filed this suit against Royal Ahold, Ahold, Landover, Stop & Shop, and Giant in United State District Court for the District of Massachusetts on May 20, 2009. On August 18, 2010, the Government notified the court that it was declining to intervene in the suit. All states named in the suit also declined to intervene [# 12], On January 19, 2011, Defendants Ahold, Stop & Shop, and Giant filed their Answer [# 23]. Defendant Royal Ahold subsequently filed a Motion to Dismiss [# 24]. On February 28, 2011, the court allowed a Stipulation Discontinuing Action with Prejudice against Royal Ahold [# 28]. The remaining parties filed a Motion for Judgment on the Pleadings on Counts I, III, and V through XI of the Complaint and for Related Relief [#35]. The court allowed Ciaschini’s motion to amend the complaint, and on May 4, 2011, Ciaschini filed the Verified Amended Complaint [# 42]. On May 6, 2011, Defendants filed a Motion to Dismiss Counts I, II, and V-XI of the Verified Amended Complaint [# 45], which is at issue here. The court held a hearing on February 14, 2012, and took the Motion to Dismiss under advisement.
III. Discussion
A. Standard for Motion to Dismiss
In order “to survive a motion to dismiss, a complaint must allege ‘a plausible entitlement to relief.’ ”
It is certain that a relator must allege more than the possibility of fraud in order to satisfy Rule 9(b) for a § 3729(a)(1) violation. The First Circuit has stated: “Articulating a theory as to how a company could violate subsection (a)(1), without more, is insufficient to comply with the requirements of Rule 9(b).”
It is not possible to provide a “checklist” of facts that a qui tam relator must include in a complaint in order to satisfy Rule 9(b).
[D]etails concerning the dates of the claims, the content of the forms or bills submitted, their identification number, the amount of money charged to the government, the particular goods or services for which the government was billed, the individuals involved in the billing, and the length of time between the alleged fraudulent practice and the submission of claims based on those practices are the types of information that may help a relator to state his or her claims with particularity. These details do not constitute a checklist of mandatory requirements that must be satisfied by each allegation included in a complaint. However, like the Eleventh Circuit, we believe that “some of this information for at least some of the claims must be pleaded in order to satisfy Rule 9(b).”52
In Karvelas, a former employee of the defendant alleged that the defendant “knowingly submitted false claims to the United States government in order to obtain Medicare and Medicaid payments, in violation of the False Claims Act.” The First Circuit upheld the district court’s ruling that the complaint did not satisfy Rule 9(b) for a violation of § 3729(a)(1) because the relator failed “to identify with particularity any false claims” actually submitted to the government.
the complaint never specifies the dates or content of any particular false or fraudulent claim allegedly submitted for reimbursement by Medicare or Medicaid. It provides no identification numbers or amounts charged in individual claims for specific tests, supplies, or services. It*34 does not identify or describe the individuals involved in the improper billing or allege with particularity any certification of compliance with federal regulations in order to obtain payments.54
The specificity requirements of Rule 9(b) also apply to violations of § 3729(a)(2).
B. Relator’s Ciaschini’s Shorting Theory
1. 31 U.S.C. § 3729(a)(1)
Ciaschini alleges that billing the government in advance for a full prescription when only a partial prescription has been filled constitutes submitting a false or fraudulent claim. He alleges that this violates the FCA even if the customer returns to pick up the remainder of his or her prescription. Ciaschini refers to this practice as shorting or front-loading. He provides detailed information regarding twenty instances when Defendants allegedly billed the government for a full prescription after only partially filling that prescription. He lists much of the information the First Circuit in Karvelas suggests “may help a relator to state his or her claims with particularity.”
Ciaschini’s shorting theory, however, ultimately fails to satisfy Rule 9(b) for a claim under § 3729(a)(1) because he does not plead facts demonstrating that false claims were actually submitted to the government. Presentment is a necessary requirement of bringing a § 3729(a)(1) claim.
Each of the twenty claims Ciaschini discusses in detail outlines how a pharmacist entered information into Stop & Shop’s computer system. This information was transmitted electronically to corporate headquarters. A close reading of the facts demonstrates that Ciaschini never indicates that the information entered by the pharmacist was actually the information submitted directly to the government as a false claim. For each of these claims, Ciaschini states that upon partially dispensing a prescription, Defendants “contemporaneously falsely billed” Medicare, Medicaid or Masshealth for the full prescription.
Paragraphs 84 and 102 of the Verified Amended Complaint underscore that Cias-
On a regular basis, the defendants’ employees would dispense partial prescriptions to Beneficiaries of programs inclusive of Medicaid, Medicare and Masshealth, and prepare false records of the transaction for the purpose of billing such health care programs, after which Corporate Headquarters would fraudulently bill those healthcare programs for the full amount of the prescriptions at issue, despite the fact that the full amounts had not been dispensed.64
Paragraph 102 discusses what would occur after an employee would enter prescription information into a pharmacy computer. It reads:
The electronic record containing such information was then immediately transmitted to, and stored within, the main computer at Corporate Headquarters, that being the same computer system through which Corporate Headquarters electronically submitted claims for payment to the Federal and State Health Care Programs.65
These two paragraphs establish that employees would submit statements to corporate headquarters implying that they dispensed the full prescription. These statements do not provide any evidence that Defendants, in turn, submitted this actual information to the federal government for reimbursement.
Even though the court did not create a checklist in Karvelas, it stated at least some minimum of specificity as to how a party submitted false claims is necessary.
Ciaschini has provided information indicating that employees prepared internal documents reflecting that prescriptions were filled in full when they were not. He has not, however, provided any evidence that these documents were the ones submitted to the government for reimbursement. He, also, has provided no evidence that any documents including false claims were actually submitted to the government. Without evidence of a false claim submitted to the government for reimbursement, there is no violation of § 3729(a)(1).
2. 31 U.S.C. § 3729(a)(2)
Relator Ciaschini has also failed to properly plead a violation of § 3729(a)(2). For a violation of § 3729(a)(2), Ciaschini does not have to prove that Defendants presented false claims for payment. In Allison Engine, the Supreme Court made it clear that § 3729(a)(2) has no presentment requirement.
Ciaschini has provided facts for twenty specific prescriptions entered into Defendant’s computer system and sent electronically to corporate headquarters. He does not, however, provide details connecting the entry of the information in the computer
The court’s stringent analysis of what satisfies Rule 9(b) for a violation of 31 U.S.C. § 3729(a)(2) is necessary in this case. A more lenient standard like the one applied by the First Circuit in Duxbury is inappropriate because Ciasehini is not alleging third-parties used information prepared by Defendants to submit false claims.
C. Relator Ciaschini’s Re-adjudication Theory
Ciasehini also alleges that Defendants did not credit (“re-adjudicate”) the government for prescriptions that they restocked. Under this theory, Ciasehini clearly fails to plead fraud with the requisite particularity.
Ciasehini offers no details in regards to his re-adjudication theory. He does not, for instance, provide (1) the date that any prescription was restocked; (2) the identification number for any prescription that was restocked; (3) the amount charged to the government for any prescription that was restocked; (4) the name of any prescription that was restocked; or (5) who, in particular, restocked a prescription. All Ciasehini does provide is a theory under which Defendants could have violated the FCA, which, without
D. Relator Ciaschini’s Lot Control Theory
Ciaschini alleges that when Defendants returned prescriptions to the shelf, they mixed drugs with different expiration dates into the same lot,
E. Relator Ciaschini’s Conspiracy Theory under 31 U.S.C. § 3729(a)(3)
In Count I of the Verified Amended Complaint, Ciaschini alleges that Defendants “conspired to defraud the Government by getting a false or fraudulent claims allowed or paid.”
F. Massachusetts False Claims Act
The Massachusetts False Claims Act (“MFCA”) is modeled on the federal FCA, and “courts use the federal FCA for guidance in interpreting the MFCA.”
Mass. Gen. Laws ch. 12, § 5B(8) imposes liability on one who “knowingly makes, uses, or causes to be made or used, a false record or statement to conceal, avoid, or decrease an obligation to pay or to transmit money or property to the commonwealth____” Here, Ciaschini has not provided evidence that Defendants violated 12, § 5B(8). Liberally construing the facts in his favor, the court assumes that Ciaschini means that after Defendants billed Masshealth for a full prescription, and the customer failed to pick up the remainder of that prescription, Defendants violated 12, § 5B(8) by not re-adjudicating payment to the Commonwealth. Defendants used the documents submitted to corporate headquarters stating that they dispensed the full prescription to conceal or avoid re-adjudicating payment. This argument fails, however, because Ciaschini, as stated above, never provides evidence that Defendants either billed Masshealth for a full prescription not dispensed or failed to re-adjudicate payment if they did.
Mass. Gen. Laws ch. 12, § 5B(9) imposes liability on one who “is a beneficiary of an inadvertent submission of a false claim to the commonwealth ..., subsequently discovers the falsity of the claim, and fails to disclose the false claim to the commonwealth____” A
G. Non-Massachusetts Claims
Relator Ciaschini also brings claims for violations of The New York False Claims Act (Count V), the Virginia Fraud Against Taxpayers Act (Count VI), The New Jersey False Claims Act (Count VII), the Rhode Island “State False Claim Act” (Count VIII), the New Hampshire False Claims Act (Count IX), the Delaware False Claims and Reporting Act (Count X), and the District of Columbia False Claims Act (Count XI). In the Verified Amended Complaint, Ciaschini only describes actions that took place within Massachusetts. He alleges that these actions were part of a corporate policy and thus took place in other states. He doesn’t however, provide any support for the theory that shorting, re-adjudicating, or mixing of lots were in fact corporate policies. The court will not rely on these unsupported “labels and conclusions.”
IV. Conclusion
For the foregoing reasons, Defendants’ Motion to Dismiss Counts I, III and V through XI of the Amended Complaint is ALLOWED. Counts I and III are dismissed with prejudice. Ciaschini filed the original complaint in 2009, and has already amended the complaint in response to a motion for judgment on the pleadings. Since the court did not address the substance of Counts V through XI, they are dismissed without prejudice to refiling in the appropriate jurisdictions. Pursuant to 31 U.S.C. § 3730(b), the Government has filed a Notice of United States’ Consent to Dismissal [# 68] stating that it consents to dismissal of these counts.
AN ORDER HAS ISSUED.
ORDER
For the reasons set forth in the accompanying memorandum, Defendants’ Motion to Dismiss Counts I, III and V through XI of the Amended Complaint [# 45] is ALLOWED.
IT IS SO ORDERED.
. 31 U.S.C. § 3730(b) (Supp. 2011).
. 31 U.S.C. § 3729(a)(1) (Supp. 2008).
. § 3729(a)(2).
. § 3729(a)(3).
. Pub.L. No. 111-21, 123 Stat. 1617.
. Allison Engine Co., Inc. v. United States ex rel. Sanders, 553 U.S. 662, 671-72, 128 S.Ct. 2123, 170 L.Ed.2d 1030 (2008).
. Even though some of Ciaschini's claims may have been pending on or after June 7, 2008, neither party references the FCA as amended by FERA. The change in the law, however, does not affect the court’s analysis. In order to avoid confusion, all references to the FCA will be to the pre-FERA section numeration unless specifically noted otherwise.
. Because the issues analyzed here arise in the context of a motion to dismiss, this court presents the facts as they are related in Relator’s Verified Amended Complaint, Trans-Spec Truck Serv., Inc. v. Caterpillar Inc., 524 F.3d 315, 321 (1st Cir. 2008), and construes those facts in the light most favorable to Plaintiff, see Pettengill v. Curtis, 584 F.Supp.2d 348, 362 (D.Mass. 2008) (quoting Rodriguez-Ortiz v. Margo Caribe, Inc., 490 F.3d 92, 96 (1st Cir. 2007)).
. V. Am. Compl. ¶ 62 [# 42].
. V. Am. Compl. ¶ 63.
. V. Am. Compl. ¶ 64.
. V. Am. Compl. ¶ 66.
. V. Am. Compl. ¶¶ 245-47.
. V. Am. Compl. ¶ 253.
. V. Am. Compl. ¶ 84.
. V. Am. Compl. ¶ 87.
. V. Am. Compl. ¶ 92.
. V. Am. Compl. ¶ 93.
. V. Am. Compl. ¶ 94.
. V. Am. Compl. V 101.
. V. Am. Compl. ¶ 104.
. V. Am. Compl. ¶ 271.
. V. Am. Compl. ¶¶ 107-225.
. V. Am. Compl. ¶ 233.
. V. Am. Compl. ¶ 232.
. V. Am. Compl. ¶ 234.
. V. Am. Compl. ¶ 239.
. V. Am. Compl. ¶ 240.
. V. Am. Compl. ¶ 241.
. V. Am. Compl. 11 242.
. V. Am. Compl. ¶ 243.
. V. Am. Compl. II32.
. V. Am. Compl. II 254.
. V. Am. Compl. ¶ 256.
. V. Am. Compl. ¶¶ 257-58.
. V. Am. Compl. ¶¶ 43-51. In the original Verified Complaint, Ciaschini named Royal Ahold, Ahold USA Inc., Stop & Shop/Giant-Landover, The Stop & Shop Supermarket Company LLC, and Giant Food LLC as defendants. In their Motion to Dismiss, Defendants state that Land-over is a non-existent entity. Mem. Supp. Defs.' Mot. Dismiss Counts I, III and V through XI of Am. Compl. Whether Landover does or does not exist has no effect on the court’s decision regarding the motion to dismiss.
. V. Am. Compl. ¶¶ 45, 50, 53.
. V. Am. Compl. II51. Ciaschini contradicts himself in the Verified Amended Complaint regarding which entities merged to form Landover. At paragraph 51 he states that Landover is a partnership and/or joint venture of Stop & Shop and Giant MD. At paragraph 56, he states that Landover was formed by a merger, partnership, and/or formation of a joint venture of Stop & Shop, Giant MD, and Giant. Lastly, at paragraph 69, he states "When Stop & Shop and Giant 'merged' into Stop & Shop/Giant-Landover .... ” Which entities merged, formed a partnership, or formed a joint venture to create Land-over is irrelevant to the court’s decision. For the sake of clarity, and in reading the facts in the light most favorable to Plaintifl/Relator, the court will assume that Landover, if it exists, consists of Stop & Shop, Giant MD, and Giant.
. V. Am. Compl. ¶¶ 69-70.
. V. Am. Compl. ¶¶ 71—72; see also V. Am. Compl. II73 ("It is the custom and practice of the pharmacists employed by the defendants at all of defendants’ business locations to electronically submit the prescription of a Beneficiary of a Federal Health Care Program to Corporate Headquarters, which, in turn, electronically submits the claim for payment to the Federal Health
. V. Am. Compl. ¶ 83 ("Upon information and belief, as a policy, procedures and custom implemented under the direction of the defendants' Corporate Headquarters, the defendants' pharmacies engaged in a fraudulent practice commonly known as billing for partíais, or 'shorting.' ”); V. Am. Compl. ¶ 239 (“the failure to re-adjudicate was a company policy which was, and is, being implemented by Corporate Headquarters for all of the defendant's stores.”). Ciaschini provides no comprehensive statement that the mixing of lots occurred at all of Defendants' stores.
. As is explained below, this refers to sections of the Code prior to the enactment of the Fraud Enforcement Recovery Act of 2009. See infra Part III.A.
. Rodriguez-Ortiz v. Margo Caribe, Inc., 490 F.3d 92, 95 (1st Cir. 2007) (quoting Bell Atl. Corp. v. Twombly, 550 U.S. 544, 559, 127 S.Ct. 1955, 167 L.Ed.2d 929 (2007)).
. Ashcroft v. Iqbal, 556 U.S. 662, 129 S.Ct. 1937, 1949, 173 L.Ed.2d 868 (2009) (internal quotations and citations omitted).
. Cordero—Hernandez v. Hernandez—Balleste-ros, 449 F.3d 240, 244 n. 3 (1st Cir. 2006).
. United States ex rel. Karvelas v. Melrose-Wakefield Hospital, 360 F.3d 220, 227-28 (1st Cir. 2004) (abrogation on other grounds recognized by United States ex rel. Gagne v. City of Worcester, 565 F.3d 40, 46 n. 7 (1st Cir. 2009)).
. United States ex rel. Rost v. Pfizer, Inc., 507 F.3d 720, 731 (1st Cir. 2007) (abrogation on other grounds recognized by Gagne, 565 F.3d at 46 n. 7) (quoting Doyle v. Hasbro, Inc., 103 F.3d 186, 194 (1st Cir. 1996)).
. Alternative Sys. Concepts, Inc. v. Synopsys, Inc., 374 F.3d 23, 29 (1st Cir. 2004).
. Gagne, 565 F.3d at 45 (quoting Karvelas, 360 F.3d at 233 n. 17).
. United States ex rel. Crennen v. Dell Marketing, L.P., 711 F.Supp.2d. 157, 162 (D.Mass. 2010).
. Karvelas, 360 F.3d at 233.
. Id. (quoting United States ex rel. Clausen v. Laboratory Corp. of America, Inc., 290 F.3d 1301, 1312 n. 21 (2002)).
. Karvelas, 360 F.3d at 235.
. Id. at 233.
. United States ex rel. Duxbury v. Ortho Biotech Products, L.P., 579 F.3d 13, 29 (1st Cir. 2009); Gagne, 565 F.3d at 45 ("We have previously held the heightened pleading requirements of Fed.R.Civ.P. 9(b) apply to claims brought under subsection (a)(1) of the FCA and subsection (a)(2).") (internal citations omitted).
. Duxbury, 579 F.3d at 30.
. Id.
. Id. at 29.
. Id. at 32.
. Karvelas, 360 F.3d at 233.
. V. Am. Compl. ¶¶ 107-225.
. See Gagne, 565 F.3d at 46 n. 7.
. See, e.g., V. Am. Compl. V 109.
. V. Am. Compl. ¶ 84.
. V. Am. Compl. ¶ 102.
. Karvelas, 360 F.3d at 233.
. Id.
. Id.
. United States ex rel. Carpenter v. Abbott Labs., Inc., 723 F.Supp.2d 395, 403 (D.Mass. 2010) (quoting Karvelas for the principle that an actual false claim is the sine qua non of a § 3729(a)(1) violation).
. 553 U.S. at 671-72, 128 S.Ct. 2123.
. Id. at 671, 128 S.Ct. 2123 (quoting § 3729(a)(2)).
. See Gagne, 565 F.3d at 46 n. 7.
. See V. Am. Compl. ¶ 102.
. When describing the twenty transactions, Ciasehini includes statements such as "the defendants ... contemporaneously falsely billed Medicare, via electronic means....” V. Am. Compl. ¶ 109. Ciasehini does not provide any details about how the allegedly false billing of Medicare or Medicaid took place contemporaneously to the dispensing of partial prescriptions. In fact, this contradicts paragraph 102 of the Verified Amended Complaint, which states that the record of the disbursement was electronically transmitted to corporate headquarters, and corporate headquarters would submit claims for payment.
. Gagne, 565 F.3d at 46 n. 7.
. Although not clearly stated in the Verified Amended Complaint, this theory appears to rest on a violation of 31 U.S.C. § 3729(a)(1).
. Karvelas, 360 F.3d at 233.
. Id.
. Id.
. Crennen, 711 F.Supp.2d. at 162.
. V. Am. Compl. ¶¶ 242-43.
. V. Am. Compl. ¶ 240.
. Fed. R. Civ. Pro. 9(b); Karvelas, 360 F.3d at 233.
. V. Am. Compl. ¶ 269.
. Iqbal, 129 S.Ct. at 1949.
. United States v. Compass Medical, P.C., No. 09-12124, 2011 WL 5508916, at *7 (D.Mass. Nov. 10, 2011); see also Massachusetts v. Scher-ing-Plough Corp., 779 F.Supp.2d 224, 234 (D.Mass. 2011) ("Massachusetts courts look to federal False Claims Act cases when interpreting the MFCA because the MFCA ‘was modeled on the similarly worded Federal False Claim Act, 31 U.S.C. § 3729 et seq.’ ”) (quoting Scannell v. Attorney General, 70 Mass.App.Ct. 46, 49 n. 4, 872 N.E.2d 1136, 1138 (Mass.App.Ct. 2007)).
. Iqbal, 129 S.Ct. at 1949.
Reference
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- UNITED STATES of America, ex rel. David R. CIASCHINI v. AHOLD USA INC.
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