Druding v. Care Alternatives, Inc.
Druding v. Care Alternatives, Inc.
Opinion of the Court
*671Table of Contents
I. INTRODUCTION...671
II. FACTUAL AND PROCEDURAL BACKGROUND...672
A. Background...672
1. Defendant Care Alternatives...673
2. Plaintiff-Relators...674
B. Hospice Care and the Medicare Hospice Benefit...675
C. Procedural History...676
D. The Evidence...677
1. Testimony And Documents About Defendants Allegedly Admitting Ineligible Patients...677
2. Plaintiff-Relators' Testimony Involving Allegations of Alteration...680
3. Dr. Jayes' Expert Report...681
4. Dr. Hughes' Expert Report...681
III. STANDARD OF REVIEW...681
IV. THE FALSE CLAIMS ACT...682
V. DEFENDANT'S MOTION TO DISMISS...683
VI. DEFENDANT'S MOTION FOR SUMMARY JUDGMENT...684
1. Plaintiff-Relators Must Put Forth Evidence of "Objective Falsity"...684
2. Plaintiff-Relators Have Not Adduced Sufficient Evidence of Objective Falsity...687
VII. CONCLUSION...689
I. INTRODUCTION
Plaintiff-Relators in this qui tam action are former employees of Defendant Care Alternatives, Inc. ("Care Alternatives" or "Defendant"), a provider of end-of-life hospice care throughout New Jersey. They bring claims on behalf of the United States under the False Claims Act ("FCA"),
Currently pending before the Court are Defendant's motions to dismiss [Docket Item 126] and for summary judgment. [Docket Item 128.] The central issues in Defendant's motion to dismiss are whether Plaintiff-Relators failed to comply with
II. FACTUAL AND PROCEDURAL BACKGROUND
A. Background
Plaintiff-Relators bring this qui tam action on behalf of the United States for alleged violations of the FCA in connection with reimbursement claims that Defendant submitted to Medicare and Medicaid between 2006 and October 23, 2007. Plaintiff-Relators generally allege a concerted effort by Defendant to bring in patients to its residential facilities who were not actually eligible for hospice care coverage under Medicare, notwithstanding that each patient was certified as hospice eligible by *673an independent physician. (See generally Am. Compl.) Specifically, the Amended Complaint identifies 15 patients whose medical records allegedly did not support a finding of terminal prognosis. (Id. at ¶ 25.)
1. Defendant Care Alternatives
Defendant Care Alternatives provided hospice care to patients throughout New Jersey. (Veltri Dep. [Docket Item 128-6] at 25:1-4, 76:4-78:1; see also Spoltore Dep. [Docket Item 128-4] at 21-1-26:25, 46:12-47-8.) To that end, Defendant employed a variety of clinicians, including registered nurses, chaplains, social workers, home health aides, and therapists, and worked with independent physicians who served as hospice medical directors.
According to Care Alternatives Hospice Administrator Loretta Spoltore ("Spoltore"),
Care Alternatives' Susan Coppola ("Coppola")
It was Care Alternatives' practice to provide education to staff members of "every *674policy and procedure, every audit form, every paper" in use by Care Alternatives. (Coppola Dep. at 96:21-97:3.) Care Alternatives employees generally received compliance training on an annual basis. (Spoltore Dep. at 95:25-96:14.) Moreover, newly-hired nurses were provided compliance orientation and then educated by their individual teams, other nurses, social workers, and chaplains so that they understood the standards of care and practice for Care Alternatives. (Id. at 34:13-35:22; see also Coppola Dep. at 97:4-97:19.) Care Alternatives' compliance training was "an ongoing educational process." (Coleman Dep. [Docket Item 130-2] at 30:17-31:2.)
In addition to its internal compliance efforts, Care Alternatives was audited by (and conferred accreditation by) Community Health Accreditation Partner ("CHAP") a non-profit, third-party accreditation agency that conducted on-site surveys of Care Alternatives. (Coppola Dep. at 14:1-7.) To that end, Care Alternatives required that all patient medical records be timely delivered and stored in its headquarter offices in Cranford, New Jersey in the event CHAP visited for an on-site review of Care Alternatives' program on short notice. [Docket Item 144-5 at 2.] Care Alternatives hired a consultant, Toni Swick, to review the medical preparation of any possible State audit or CHAP review. (Veltri Dep. at 145:1-146:6.)
2. Plaintiff-Relators
Plaintiff-Relators Victoria Druding, Linda Coleman, Barbara Bain, and Ronni O'Brien are former Care Alternatives employees. (Am. Compl at ¶ 1.)
a. Victoria Druding
Victoria Druding ("Druding") was employed by Care Alternatives as a Regional Manager of the Southwest Region for almost six months, from April 17, 2007 through September 6, 2007, when she quit without giving notice. (Druding HR File [Docket Item 128-11] at 1-2; Druding Dep. at 23:1-23:18.) As Regional Director, Druding was responsible for management of the clinical team, which included nurses, social workers, chaplains, and directors. (Id. at 23:13-25:1.) She was also responsible for ensuring that IDT meetings were scheduled and held in a timely manner. (Id. )
b. Linda Coleman
Linda Coleman ("Coleman") was employed by Care Alternatives as a Registered Nurse ("RN") Case Manager in the Southwest Region of New Jersey from April 2004 to September 2007. (Coleman Dep. at 9:18-10:1, 12:20-14-8.) As RN Case Manager, Coleman's duties were to "visit patients wherever they were... [and] trying to develop relationships for more referrals." (Id. at 8:15-21.) According to Coleman, her job "was to be the coordinator for patient care, ... [which] involved making sure the patient was in a safe environment, had a caregiver, had a physician that was willing to work with hospice, medications necessary, pulling in the rest of the team.... It was my responsibility to make sure that that all happened in a timely fashion for the care and comfort of the patient." (Id. at 14:18-15:6.)
c. Barbara Bain
Barbara Bain ("Bain") was employed by Care Alternatives as a Chaplain in the Southwest Region of New Jersey from December 28, 2003 to 2007. (Bain Dep. [Docket Item 130-3] at 8:15-9:4, 10:20-11:11, 12:4-6.) According to Bain, her job was more spiritual than religious, and she was responsible for helping patients feel good with themselves and repair their relationships with a church, their family, or themselves. (Id. at 15:8-17.) Bain testified that, as a member of the IDT, she always participated in the IDT meetings where patient care and hospice eligibility were discussed. (Id. at 25:19-26:18, 32:10-33:17.)
*675d. Ronni O'Brien
Ronni O'Brien ("O'Brien") was employed as a Community Education Liaison for the Southwest Region of Care Alternatives New Jersey. (O'Brien Dep. [Docket Item 128-15] at 11:17-12:21.) O'Brien's job was to bring in patient referrals and admissions, and she reported to marketing director Colleen Swick, (id. at 10:16-24), and she regularly participated in weekly marketing phone calls with Colleen Swick and Care Alternatives CEO Sam Vetri. (Id. at 73:4-74:15.) O'Brien was not a clinician and had no training or responsibility for evaluating patients for hospice eligibility. (Id. at 39:7-15.)
B. Hospice Care and the Medicare Hospice Benefit
Congress established the Medicare Hospice Benefit ("MHB") in 1983. See
A patient who has been certified as eligible for hospice and who elects to receive hospice care voluntarily waives the right to Medicare payment for curative treatment, and instead receives only palliative care to manage pain or other symptoms of their terminal prognosis. See 42 U.S.C. § 1395d(2)(A). A Medicare beneficiary is eligible for the MHB if his or her attending physician and a hospice medical director certify that the individual is terminally ill.
The MHB provides two 90-day benefit periods for eligible patients, followed by an unlimited number of 60-day benefit periods. 42 U.S.C. § 1395f(a)(7)(A) ;
The Centers for Medicare & Medicaid Services ("CMS"), which is responsible for administering the MHB, has stated that:
Recognizing that prognoses can be uncertain and may change, Medicare's benefit is not limited in terms of time. Hospice care is available as long as the patient's prognosis meets the law's six *676month test. This test is a general one. As the governing statute says: 'The certification of terminal illness of an individual who elects hospice shall be based on the physician's or medical director's clinical judgment regarding the normal course of the individual's illness.' CMS recognizes that making medical prognostication of life expectancy is not always an exact science. Thus, physicians need not be concerned. There is no risk to a physician about certifying an individual for hospice care that he or she believes to be terminally ill.
CMS's Program Memorandum Intermediaries/Carriers, Subject: Provider Education Article: "Hospice Care Enhances Dignity and Peace as Life Nears Its End," CMS-Pub. 60AB, Transmittal AB-03-040 (Mar. 28, 2003).
CMS has not created clinical benchmarks that must be satisfied to certify a patient as terminally ill. See
C. Procedural History
On April 29, 2008, Plaintiff-Relators filed the original Qui Tam Complaint on behalf of the United States in camera and under seal in accordance with
On September 25, 2015, Defendant filed its first motion to dismiss [Docket Item 27], which the Court granted in part and denied in part in an Opinion and Order dated February 22, 2016. [See Docket Items 47 & 48.] The Court dismissed without prejudice and with leave to amend Plaintiff-Relators' claims regarding altered documentation and violations of the Anti-Kickback Statute arising under an implied legally false theory under the FCA and the NJFCA, and dismissed with prejudice Plaintiff-Relators' claims alleging violations of the Stark Act and noncompliance with the IDT requirement. Druding v. Care Alternatives,
On March 8, 2016, Plaintiff-Relators notified the Court they were electing not to file a motion for leave to file a Second Amended Complaint, but instead "will proceed in the matter regarding inappropriate *677patient admission and re-certifications for hospice care as set forth in the [February 2016] Order." [Docket Item 49 at 1.]
Currently pending before the Court are two motions filed concurrently by Defendant: a motion to dismiss pursuant to
D. The Evidence
The evidence consists of: (1) deposition testimony and documents regarding whether Defendant improperly admitted ineligible patients; (2) deposition testimony alleged to establish that Defendant directed its employees to alter certifications; (3) a report by Plaintiff-Relators' expert, Dr. Jayes, in which he reviewed patient records for 48 Care Alternatives patients to evaluate the patients' eligibility for hospice care; and (4) a report by Defendant's expert, Dr. Hughes, in which he addressed Dr. Jayes' findings.
1. Testimony And Documents About Defendants Allegedly Admitting Ineligible Patients
During discovery, Care Alternatives produced almost 50,000 pages of documents. [Docket Item 128-17.] Plaintiff-Relators were also deposed, as were several other Care Alternatives employees. The documents and testimony addressing whether Defendant admitted ineligible patients are summarized as follows:
a. Druding's Testimony
Plaintiff-Relator Druding testified that patient A.P. could "walk without limitations, without assistance," "could talk as well as you and I are talking right now," was "always ... able to [string together multiple sentences in a conversation," "was gaining weight," and "her weight was going up instead of down." (Druding Dep. at 198:3-5, 198:17-18, 199:5-11.) According to contemporaneous nursing assessments which Druding herself authenticated (id. at 214:21-215:3; 218:11-20), however, Druding documented that the same patient was "wheelchair restricted [which] means they're restricted to the wheelchair, they're not going anywhere without the wheelchair," had lost 43 pounds while on hospice, and that the "Undersigned [Druding] has deterimined patient remains hospice appropriate as evidenced by ... weight loss despite a rigorous feeding program ... [increased] lethargy, increase sleeping, decreased communication, increase in need for assistance, decrease [in] socialization." (See Nursing Assessment [Docket Item 130-5] at 2-7.) Notwithstanding these discrepancies, as discussed infra, Druding insists that she never falsified documentation in patient medical records. (See Druding Dep. at 53:20-54:13; 63:18-64:1; see also Pl.'s Response to Def.'s Second Request for Admission [Docket Item 126-3] at ¶ 2.)
Druding testified that she knew of a Care Alternatives physician certifying a patient as terminally ill when the physician did not believe it to be true, but could not provide any supporting information.
*678(Druding Dep. at 144:20-149:22.) She also testified that she did not know if any physician was pressured by Care Alternatives employees to certify a patient for hospice at all, let alone to certify a patient who was not appropriate for hospice care. (Id. at 109:20-23.)
b. Coleman's Testimony
Plaintiff-Relator Coleman identified two patients, W.B. and H.J., as not appropriate or eligible for hospice. With respect to W.B., Coleman testified that she was instructed by Druding to check off the box for W.B. indicating he was only able to speak six intelligible words or fewer (which would qualify him for hospice care), even though the patient was, in fact, able to speak more than six words (which would not qualify him for hospice care). (Coleman Dep. at 156:14-158:3.) As Coleman explained, "This man did not, was not able, if I understand or reading my notes correctly ... this was a patient that the facility wanted us to admit because he was above and beyond what they were capable of handling. So this was one of those that was pressed on us to admit this patient, to find a diagnosis and to put him on, okay to keep our census up and to be accommodating the facility." (Id. at 157:6-16.) With respect to H.J., Coleman testified that he was schizophrenic (which would not qualify him for hospice care), but she was still pressured by Druding to admit the patient for "dementia with depression" (which would qualify him for hospice care) when he did not actually meet the criteria for such a diagnosis. (Id. at 171:19-173:23.) Nevertheless, as discussed infra, Coleman maintains she never altered or falsified any patient's medical records.
Coleman testified that she recalled one instance "where our medical director felt that the patient was questionable [and] ... maybe a diagnosis needed to be different or whatever." (Id. at 34:1-7.) But Coleman could not recall whether the medical director was Dr. Uwewemi or Dr. Dignam and she could not remember the name of the individual patient. (Id. at 34:9-12.) When asked about any other specific recollections she might have, Coleman testified "I can't give you any names of patients or whatever, but just concerns with, you know, length of stay, type of diagnosis, what the patient is actually able to do." (Id. at 51:1-4.)
Coleman never reported any hospice eligibility concerns to Care Alternative's compliance department (id. at 48:18-49:3), but testified that she complained to her coworkers, including Druding, regarding the working conditions at Care Alternatives, and voiced her concerns about inappropriate patient admissions, certifications, and recertifications during IDT meetings. (Id. at 50:23-51:4, 53:21-55:4, 65:6-14.)
Coleman recalled that when she raised any concerns at IDT meetings, the physicians' reactions were "[a]ttentive and checking information in the record that they had before them, the copies, and discussing with the regional manager." (Id. at 52:1-5.) Coleman also testified that, in her experience the hospice medical directors were "absolutely" engaged during discussions at IDT meetings about patients and were "[v]ery proactive" (id. at 35:20-25), and that, in her opinion, Dr. Uwemi and Dr. Dignam "absolutely" had the patient's best interest at heart. (Id. at 52:6-16.) Furthermore, Coleman testified that she did not believe that any medical directors or other physicians affiliated with Care Alternatives were certifying patients for hospice when they did not believe that the patients were terminally ill. (See Coleman Dep. at 43:5-19.) ("Q: Did you ever have a belief that either of the physicians you remember, Dr. Dignam or Dr. Uwewemi, were certifying patients for hospice when they didn't believe the patient to be terminally *679ill? A: No. I really don't think that they did.... Q: Did either of the medical directors ever tell you that they didn't think a patient was appropriate for hospice? A: No."). When asked: "Do you have firsthand knowledge of a physician certifying a patient as terminally ill when the physician did not believe the certification to be true?" Coleman responded, "No." (Id. at 67:8-12.)
c. Bain's Testimony
Plaintiff-Relator Bain testified that, while she is not a clinician and does not have any formal training on hospice eligibility (Bain Dep. at 16:4-23), in her estimation, 90 percent of patients at Care Alternatives were appropriate for hospice. (Id. at 86:11-87:2.) Bain never reported any concerns about patient eligibility to Care Alternative's compliance department (id. at 81:1-82:18), but she testified that she reported concerns about patient eligibility at IDT meetings. (Id. at 34:14-35-17.) Bain also testified that she had no firsthand knowledge of any physician having certified a patient as terminally ill at Care Alternatives when the physician did not believe the patient to be terminally ill. (Id. at 101:18-102:1.)
d. O'Brien's Testimony
Plaintiff-Relator O'Brien never reported any concerns about patient eligibility to Care Alternatives' compliance department (id. at 43:6-54:7), but testified that she complained about her concerns regarding hospice eligibility to her supervisor, Colleen Swick. (Id. at 43:3-44:24.) According to O'Brien, Colleen Swick responded that the issue of hospice eligibility was "not her concern" because she was not a nurse and "could not make diagnoses." (Id. ) O'Brien also testified that, on weekly calls, Colleen Swick and Vetri instructed employees to "build the census no matter how they did it" and "bring me bodies." (Id. at 73:4-74:15.) O'Brien testified that she discussed inappropriate hospice admissions with other Care Alternatives regional marketing personnel from other regions of the company. (Id. at 42:22-43:2.)
e. Kelton's Testimony
In August 2007, Care Alternatives' Lauren Kelton ("Kelton")
Kelton further testified that, during her entire tenure at Care Alternatives, she never heard or received any report or allegation that any employee or contractor of Care Alternatives, other than Druding, had ever pressured any person to admit a patient who was not appropriate for hospice. (Kelton Aff. at ¶ 10.) According to Kelton, Care Alternatives "was dedicated to abiding by applicable rules and regulations and always endeavored to 'do the right thing.' " (Id. at ¶ 11.) Throughout her time as an employee of Care Alternatives, Kelton "never had any concerns that Care Alternatives was engaging in a practice of admitting patients who were inappropriate for hospice or keeping patients on elevated levels of care who did not warrant that level of care." (Id. at ¶ 12.)
f. Coppola's Testimony
Coppola, Care Alteratives' Chief Compliance Officer, testified that she never heard or received any report that any nurse had been pressured to document improper hospice diagnoses, and that if she had received such a report, she would have addressed it immediately and supported the nurse who reported it. (Coppola Dep. at 99:1-18.)
g. Spoltore's Testimony
Care Alternatives Hospice Administrator Spoltire testified that she never received reports from nurses or case managers questioning a patient's appropriateness for hospice or the length of the stay, nor did she ever hear of pressure to admit patients who were not appropriate for hospice. (Spoltore Dep. at 158:12-160:9.)
h. Veltri's Testimony
Care Alternatives CEO Sam Veltri ("Veltri") testified that he never received any reports that Care Alternatives was maintaining patients who were inappropriate for hospice and that if he had received such a report, he would "have taken immediate steps to get to the bottom of that." (Veltri Dep. at 157:10-158:2.)
2. Plaintiff-Relators' Testimony Involving Allegations of Alteration
Druding testified that Toni Swick instructed her "in a group with regional managers and individually in discussion" to falsify, alter, or otherwise change medical documentation. (Druding Dep. at 53:16-18; 63:5-11.) According to Druding, "[w]hen we audited charts, if we found something that ... did not promote compliance, whether it was fact or not, we were to change it." (Id. at 53:20-24.) Druding testified, however, that she never made these changes herself, including in the case of A.P. discussed above, because she could have sacrificed her nursing license if she had. (Id. at 54:9-13.) Instead, Druding testified, various unnamed "members of the staff," including nurses, chaplains, and social workers falsified, altered, or otherwise changed documents "upon instruction." (Id. at 54:17-20.) Druding could not identify any specific individuals who falsified, altered, or otherwise changed documents. (Id. at 54:21-55:12; see also
Coleman testified that in August 2007 Druding directed her to "make the chart complete," which meant "[w]hatever it required. If notes were missing, which there were many missing, they wanted them regenerated you know...." (Coleman Dep. at 80:16-22; 77:1-17; 80:12-14; see also
*681A: By Victoria. Sorry.") Coleman testified that, notwithstanding these instructions, she never entered documentation in medical records that she knew was not true, nor did she know of anyone who did. (Id. at 89:16-90:16.)
O'Brien testified that she was generally aware of Care Alternatives employees, including Druding and two unnamed social workers, going up to "change records" and "write whatever needed to be written in the charts." (O'Brien Dep. at 62:15-20; 64:5-24; 65:11-12.) However, O'Brien clarified, "Nobody had said that they falsified." (Id. at 65:3-6.) O'Brien also testified "I don't know exactly what they did. I was not there. I was not privy to see." (Id. at 65:13-14.)
3. Dr. Jayes' Expert Report
On August 20, 2017, Plaintiff-Relators' expert, Dr. Robert Jayes, M.D., prepared a report summarizing a review he conducted of the medical records for 47 patients whose records Care Alternatives produced during discovery, including the 15 patients identified in paragraph 25 of the Amended Complaint. (See Jayes Report [Docket Items 130-6 & 130-7].) In his report, Dr. Jayes explained that "[d]etermining the prognosis of patients with a serious terminal illness referred to hospice is a difficult task that depends on the judgment and experience of clinicians and the consideration of survival evidence from the literature." (Id. at 1.) "Recognizing this difficulty," Dr. Jayes looked to guidelines provided with the assistance of clinical experts from the National Hospice and Palliative Care Organization in the mid 1990's, as well as "several other criteria typically employed by hospice professionals," to determine whether documentation supported certification and/or recertification of the 47 patients he reviewed for hospice. (Id. at 1-3.)
According to Dr. Jayes, 214 out of 603 (or 35%) of the periods of hospice certification periods he reviewed lacked documentation supporting hospice care. (Id. at 1.) Dr. Jayes further opined that of the 47 patients whose records he reviewed, 26 were appropriate for hospice at all times and 16 more were appropriate for at least a part of their stay in hospice. (Id. at Appendix A.) Of the 15 patients identified in the Amended Complaint, Dr. Jayes opined that 8 were appropriate for hospice care for the entirety of their time in hospice while 4 more were appropriate for the majority of the time they were in hospice. (Id. at 19.) Dr. Jayes also found that at least 3 medical records appeared to be incomplete because those records were cut off at December 31, 2009 even though the patient apparently remained in hospice. (Id. at 7.)
4. Dr. Hughes' Expert Report
For each benefit period where Dr. Jayes determined that a patient was inappropriate for hospice based on his review of the medical records, Defendant's expert, Dr. Christopher Hughes, M.D., reviewed Dr. Jayes' findings. (Dr. Hughes Report [Docket Item 130-1].) In each instance, Dr. Hughes, based on his experience and clinical judgment, found it to be reasonable that a physician would have certified each patient Dr. Jayes reviewed for hospice during the benefit period in question. (Id. at 31-50.)
III. STANDARD OF REVIEW
At summary judgment, the moving party bears the initial burden of demonstrating that there is no genuine dispute as to any material fact and the movant is entitled *682to judgment as a matter of law. Fed. R. Civ. P. 56(a) ; accord Celotex Corp. v. Catrett,
A factual dispute is material when it "might affect the outcome of the suit under the governing law," and genuine when "the evidence is such that a reasonable jury could return a verdict for the nonmoving party."
IV. THE FALSE CLAIMS ACT
Under the FCA, private individuals can bring qui tam actions on behalf of the government in exchange for their right to retain some portion of any resulting damages award. United States ex rel. Wilkins v. United Health Group, Inc.,
Liability may attach under the FCA on two different theories: the presentment of factually false claims and the presentment of legally false claims. Wilkins,
*683Universal Health Services v. United States ex rel. Escobar, --- U.S. ----,
V. DEFENDANT'S MOTION TO DISMISS
Defendant first argues that the Amended Complaint should be dismissed because Plaintiff-Relators failed to comply with the statutory requirements of
According to Defendant, Plaintiff-Relators deliberately withheld material information in its "Written Disclosure of Substantially all Material Evidence and Information with Respect to Alleged False Claims" (the "Written Disclosure Statement"), which was served to the Government around the time the Complaint was filed in April 2008. [Docket Item 127 at 5-6.] Specifically, Defendant maintains that Druding's own deposition testimony revealed that "Druding was the person who directed the conduct falsely attributed to Care Alternatives in the Complaint and that she was the subject of an internal compliance investigation where she admitted to this activity before immediately resigning." [Id. at 5.] According to Defendant, Druding testified at her deposition that she falsified medical records in connection with services provided to one patient, A.P., and this information was not included in the Written Disclosure Statement to the Government. [Id. at 7.] By "deliberately omitting" and "improperly with[holding]" this "material" information from the Written Disclosure Statement, Defendant argues, Plaintiff-Relators failed to comply with their pre-suit disclosure requirements under
In response, Plaintiff-Relators argue: (1) Defendant lacks "statutory" standing to seek dismissal for a purported violation of
In Rigsby, the Supreme Court held that a district court may (but is not required to) dismiss a qui tam complaint for failure to comply with
The Court assumes for purposes of deciding this motion to dismiss that Lujan articulated the proper test for dismissal due to a deficient Section 3730(b)(2) written disclosure statement.
First , Defendant has failed to show that the Government was actually harmed by the supposedly deficient Written Disclosure Statement, and "[t]he mere possibility that the Government might have been harmed by disclosure is not alone enough reason to justify dismissal of the entire action." Lujan,
Second , to the extent the Written Disclosure Statement was deficient, Plaintiff-Relators' alleged violation (i.e., failure to disclose that Druding had, herself, apparently falsified the records of one patient, A.P.) was not necessarily "severe" in the context of a FCA action where Plaintiff-Relators had also identified 14 other patients in the Amended Complaint who allegedly received inappropriate hospice care.
Third , despite Defendant's hyperbolic rhetoric, there is no evidence that any omissions in the Written Disclosure Statement were the result of deliberate bad faith or willfulness on Plaintiff-Relators' part.
It also appears there have been no cases in which a defendant won dismissal of an FCA complaint where the purported
For these reasons, the motion to dismiss will be denied.
VI. DEFENDANT'S MOTION FOR SUMMARY JUDGMENT
In its motion for summary judgment, Defendant argues that: (1) Plaintiff-Relators' allegations of falsity have insufficient evidentiary support; (2) there is insufficient evidence that Defendants submitted legally false claims; (3) Plaintiff-Relators have not satisfied the element of "materiality;" and (4) Plaintiff-Relators have not adduced any evidence of scienter under the FCA. Because the Court finds that summary judgment is warranted on the first basis for the reasons described below, the Court need not address Defendant's other arguments.
1. Plaintiff-Relators Must Put Forth Evidence of "Objective Falsity"
As an initial matter, the Court finds persuasive the district courts' analyses in United States v. AseraCare, Inc. ("AseraCare I"),
In AseraCare, the United States intervened in a qui tam action alleging that the medical records of 123 patients at issue in the case did not contain "clinical information and other documentation that support [this] medical prognosis," and thus, the defendant hospice provider's reimbursement claims for those patients were "false." AseraCare II,
After hearing evidence at a jury trial and then granting a new trial based on improper instructions the court gave to the jury regarding "false claims," see AseraCare I,
Similarly, in Vista Hospice, the Northern District of Texas granted summary judgment in favor of a defendant hospice provider as to false claims allegations alleged by a qui tam relator who sought to prove that the hospice provider had submitted false reimbursement claims for inappropriate patients. There, the evidence consisted of two expert reports, as well as documents and testimony alleged to establish "a culture of admitting and maintaining patients who were ineligible for hospice," including deposition testimony of the relator and other employees who "describe[d] pressure allegedly imposed on them and others to falsify information in patient charts, which allegedly resulted in such information being falsified, and physicians certifying patients without reviewing patient files." VistaHospice,
First, the court explained that, "[b]ecause a physician must use his or her clinical judgment to determine hospice eligibility, an FCA claim about the exercise of that judgment must be predicated on the presence of an objectively verifiable fact at odds with the exercise of that judgment, not a matter of questioning subjective clinical analysis." Id. at *17 (citing Morton,
Next, the court considered relator's proffered evidence regarding the defendant hospice provider's corporate culture and allegations of altered medical documents. As the court observed, the relator produced "some evidence of the Defendants' pressure on their employees to admit large numbers of hospice patients, and that a few employees falsified data on a few specified patient charts...," but failed to adequately "tie[ ] that evidence to the patients whose charts [the expert] evaluated, nor to the submission of a single false claim."
Finally, the court determined that, "[n]o reliable evidence is presented by Relator that any patient was not terminally ill." Id. Although the relator and other non-physician employees "claim that they were involved in or observed the certification of patients who were medically ineligible, ... eligibility depends on physician judgment, and thus, their allegations about patient health cannot support a conclusion that *687any patient for whom a claim was submitted had a medical prognosis of more than six months." Id. (emphasis in original) (citing United States ex rel. Geschrey v. Generations Healthcare, LLC,
Again, the Court finds the reasoning in AseraCare and Vista Hospice persuasive. The logic of these cases is also supported by the Third Circuit's FCA caselaw. See United States ex rel. Thomas v. Siemens AG,
2. Plaintiff-Relators Have Not Adduced Sufficient Evidence of Objective Falsity
As in AseraCare and Vista Hospice, Plaintiff-Relators identified patients in the Amended Complaint who were allegedly inappropriate for hospice care. (See Am. Compl. at 25.) As in AseraCare and Vista Hospice, Plaintiff-Relators conceded that every patient identified in the Amended Complaint was certified by appropriate physicians for the hospice benefit, as required by 42 U.S.C. § 1395f(a)(7). Druding,
As detailed in Section II.D.1, supra, Plaintiff-Relators' deposition testimony mostly reveals that, contrary to the allegations in the Amended Complaint, the only person who put any direct pressure on nurses or other Care Alternatives employees to admit ineligible patients for hospice was Druding herself. (See, e.g., Coleman Dep. at 156:14-158:3; 171:19-173:23.) This is corroborated by Kelton's August 2007 *688internal investigation, which revealed that nurses reported feeling pressured by Druding, and only Druding, to admit patients whom the nurses believed were inappropriate for hospice (see Kelton Aff.), as well as the deposition testimony of several Care Alternatives Employees, including Coppola, Spoltore, and Veltri.
Nor is there evidence of alteration or falsification of any identified patient's record. As noted above, the Court previously dismissed without prejudice Plaintiff-Relators' allegations that Care Alternatives "submitted false claims for reimbursement by presenting to the Government claims based on altered medical records." Druding,
The only remaining evidence of falsity that Plaintiff-Relators have put forth is the expert report of Dr. Jayes. But, as Third Circuit precedent makes clear, the difference of opinion of an expert cannot be false. Hill,
In sum, Plaintiff-Relators have not adduced sufficient evidence of falsity sufficient to raise a genuine dispute of material fact. Accordingly, summary judgment must be granted in favor of Care Alternatives.
VII. CONCLUSION
In light of the foregoing, the Court will deny Defendant's motion to dismiss and grant Defendant's motion for summary *689judgment. An accompanying Order will be entered.
Pursuant to Local Civil Rule 56.1, the Court distills this version of the facts from the First Amended Qui Tam Complaint (hereinafter, "Am. Compl.") [Docket Item 12] when appropriate, Defendant's Statement of Undisputed Material Facts [Docket Item 131], Plaintiff-Relators' Response in Opposition to Defendant's Statement of Undisputed Material Facts [Docket Item 144-7], Defendant's Reply to Plaintiff-Relators' Response [Docket Item 160], and related exhibits and documents attached thereto.
The Court will, however, only consider properly documented citations in Plaintiff-Relators' "Counterstatement of Material Facts." [See Docket Item 144-8.] In addition to requiring the opponent of summary judgment to "furnish, with its opposition papers, a responsive statement of material facts," which Plaintiff-Relators filed [see Docket Item 144-7] and the Court will consider as stated above, Local Civil Rule 56.1 permits the opponent of summary judgment to "furnish a supplemental statement of disputed material facts, in separately numbered paragraphs citing to the affidavits and other documents submitted in connection with the motion, if necessary to substantiate the factual basis for opposition." See L. Civ. R. 56.1 (emphasis added). Plaintiff-Relators' Counterstatement does not comply with this rule. The Counterstatement reads like argument, either untethered to specific cites to the record or citing to material in the factual record that does not support the generalized arguments in the Counterstatement.
While Plaintiff-Relators' Counterstatement is technically separated by numbered paragraphs and cites record evidence at the end of each paragraph, many paragraphs contain numerous sentences, including up to nine sentences in at least two instances (see, e.g., ¶¶ 91, 93), and fails to identify in any meaningful way which sentence in each paragraph is purportedly substantiated by which affidavit and/or other document submitted in connection with the motion. The Court is unable to easily discern whether each sentence (i.e., statement) in the Counterstatement is, in fact, supported by the voluminous record, which stands nearly three feet high, and will not endeavor to do so here. See Decree v. United Parcel Serv., Inc.,
This Court has invested a great deal of time in examining the parties' submissions, but there are limits beyond which the Court must rely on the advocates' substantial compliance with their obligations in summary judgment practice in a complex factual case. "The purpose of the Rule 56.1 statement is for the parties to identify the facts relevant to the pending motion so the Court may determine whether a genuine dispute exists without having to first engage in a lengthy and timely review of the record." Vibra-Tech Engineers, Inc. v. Kavalek,
Defendant did not employ the physicians who certified its patients for the hospice benefit. (Spoltore Dep. at 59:8-60:2.) Rather, these physicians were either independent contractors or agents of contractors (in the case of hospice medical directors) or not affiliated with Care Alternatives at all (in the case of physicians who served only in an attending capacity). (Id. at 37:13-23; see also Veltri Decl. [Docket Item 128-6] at ¶ 4.) Compensation for medical directors was fixed, set in advance, and did not vary based on the number of patients a physician certified for hospice. (Id. at ¶ 5.) According to Plaintiff-Relator Druding, however, Care Alternatives kept score of each medical director's patient referrals and, if doctors did not provide enough referrals, Care Alternatives parted company with the doctors. (Druding Dep. at 224:21-225:5.)
Spoltore was the person responsible for overseeing the day-to-day operations of Care Alternatives' clinical program for New Jersey from November 2005 through January 2010. (Spoltore Dep. at 8:7-11:6.)
From 2006 to 2011, Coppola worked in the compliance department at Care Alternatives, ultimately reaching the level of Chief Compliance Officer. (Coppola Dep. at 12:3-23.)
Between January 23, 2006 and 2011, Medicare Hospice regulations specifically defined "hospice" as "a comprehensive set of services described in 1861(dd)(1) of the [Social Security] Act, identified and coordinated by an interdisciplinary group to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care." [Docket Item 144-1 at 2-35.]
"An individual is considered to be 'terminally ill' if the individual has a medical prognosis that the individual's life expectancy is 6 months or less." 42 U.S.C. § 1395x(dd)(3)(A) (eff. Dec. 29, 2007); see also
Kelton was the Clinical Director of Care Alternatives New Jersey from 2007 to early 2009 and, in this role, she oversaw clinical operations in New Jersey, which included oversight of and involvement with clinical documentation practices, corrective action plans, and issues relating to hospice admissions and elevated levels of care. (Kelton Aff. at ¶¶ 2-4.)
Defendant indicated that a motion to exclude the testimony of Dr. Jayes based on unreliable methodology is "forthcoming." [Docket Item 129 at 26 n. 12.]
Plaintiff-Relators argue, unpersuasively, that the Court should look to the six-factor test outlined in Poulis v. State Farm Fire & Cas. Co.,
The Court notes that AceraCare is currently pending on appeal. See USA v. AseraCare, Inc., App. No. 16-13004 (11th Cir., filed on May 26, 2016).
Reference
- Full Case Name
- Victoria DRUDING, Barbara Bain, Linda Coleman, and Ronni O'Brien, Plaintiff-Relators v. CARE ALTERNATIVES, INC.
- Cited By
- 5 cases
- Status
- Published