Earlier this month, the U.S. District Court for the Middle District of Tennessee dismissed a relator’s qui tam lawsuit, finding that the relator had failed to adequately allege the presentment of false claims to the government. In U.S. ex rel. Prather v. Brookdale Senior Living, Inc., the relator alleged that Brookdale submitted false claims for home health services that did not meet the technical requirements for billing under Medicare rules and regulations. Defendants argued that the allegations failed to include sufficient detail regarding the actual submission of requests for anticipated payment (RAP) claims and that the relator failed to plead the requisite legal falsity of both RAP and final episode payment claims.
The district court dismissed the second amended complaint with prejudice, finding that the relator did not meet the “strict requirement” that she allege the submission of actual false claims to a federal healthcare program. The district court found that despite including information regarding treatment dates, the entity providing the treatment, and the Brookdale community at which the patient resided for four exemplar patients and several hundred patients in attached exhibits, the complaint failed to allege the presentment of any false claim. The district court held that it was “insufficient for Prather to point to a patient that received home health care services and allege that a RAP was, or must have been, submitted, by some corporate authorization, for some amount, at some date around the date of treatment, and that some payment was likely received in return from the government, based just on the generally delineated circumstances of the patient’s receipt of home health services from a defendant entity.” The information provided was “too general and too attenuated from the Medicare Billing process to satisfy the requirements of the law concerning the presentment of specific false claims.”
The district court went on to find that the relator failed to allege the falsity of any claims. The relator claimed that home health billing was rendered false when Brookdale did not obtain physician certifications or face-to-face documentation until after the episode was completed. The court found that longstanding CMS policy only required that this documentation be obtained before the final episode claim was billed, even where regulations require that this documentation be obtained “as soon as possible” after the establishment of a plan of care. 42 C.F.R. § 424.22. Relator’s claims did not allege any violation of Medicare laws and regulations that would render any claims false under an implied certification theory.
The district court had previously dismissed the relator’s first amended complaint in a March 31 opinion. There, the district court similarly held that the complaint must be dismissed where it failed to allege that a specific false claim was actually submitted to the government.