Balderson v. Lincare Inc.

District Court, S.D. West Virginia·Decided October 13, 2020·No. 2:19-cv-00666·Unknown

Opinion

IN THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN DISTRICT OF WEST VIRGINIA

CHARLESTON DIVISION

CHANDRA BALDERSON, et al.,

Plaintiffs,

v. CIVIL ACTION NO. 2:19-cv-00666

LINCARE INC.,

Defendant.

MEMORANDUM OPINION AND ORDER Pending before the Court are Defendant Lincare Inc.’s (“Defendant”) Motion for Summary Judgment, (ECF No. 84), Defendant’s Motion for Partial Summary Judgment, (ECF No. 86), and Plaintiff Chandra Balderson’s (“Plaintiff”) Motion for Partial Summary Judgment, (ECF No. 88). For the reasons discussed more fully below, Defendant’s Motion for Summary Judgment, (ECF No. 86), is DENIED IN PART and GRANTED IN PART. Further, and for the reasons explained more fully below, Defendant’s Motion for Partial Summary Judgment, (ECF No. 86), is DENIED. Finally, and again for the reasons more fully explained below, Plaintiff’s Motion for Partial Summary Judgment, (ECF No. 88), is DENIED AS MOOT. I. BACKGROUND This action arises out of the alleged wrongful termination of Plaintiff’s employment by her employer, Defendant Lincare Inc. Defendant is a supplier of respiratory care services and equipment for home use. (ECF No. 85 at 1.) Plaintiff is a former sales representative who was hired by Defendant in November 2015 at Defendant’s Parkersburg, West Virginia location. (ECF Nos. 85 at 1; 94 at 2.) A. Plaintiff’s Employment Responsibilities and Defendant’s Operations As a sales representative, Plaintiff had the responsibility of making sales calls each week

to Defendant’s referral sources, establishing and maintaining relationships with those referral sources, preparing sales plans, and understanding insurance and billing procedures. (ECF No. 85 at 1.) Plaintiff was eligible for earning a commission when she completed a “sale,” which meant that an order for service or equipment was placed by a physician and other certain requirements were satisfied. (Id. at 2.) The commission was to be paid in accordance with Defendant’s “Commission Structure for Commissioned Sales Representatives” (the “Commission Structure”). (Id.) Upon her hiring, Plaintiff read and signed the Commission Structure, thereby indicating her understanding of and agreement to it. (Id.) The Commission Structure established, in pertinent part, as follows: [N]o commission shall be deemed earned by, or will be payable to, any Sales Representative for any patient set-ups which are found (based on the reasonable judgment of the Corporate Compliance Officer) to be in violation of Lincare’s Compliance Program . . . if the Sales Representative had personal knowledge of the violation and failed to report it to the Corporate Compliance Officer.

(Id.) Plaintiff was the only sales representative at Defendant’s Parkersburg location who was eligible to receive commissions. (Id.) As a supplier of respiratory care services and equipment, Defendant is subject to both federal and state statutory and regulatory standards. (See ECF No. 84-6 at 2.) To foster compliance with these standards, Defendant has implemented a “Corporate Compliance Program” (the “Compliance Program”) that imposes duties on its employees that are more expansive and 2 comprehensive than any specific statutory or regulatory requirement. (See generally id.; ECF No. 85 at 2.) The Compliance Program encompasses various policies and procedures, including a code of conduct, training modules, and portions of the employee handbook. (ECF No. 85 at 3.) Defendant’s Chief Compliance Officer is responsible for investigating any potential compliance

violations. (Id.) Among these policies, the Compliance Program specifically prohibits employees from “offering or giving valuable property, equipment, services, gifts or other benefits to a person in exchange for the referral of patients to the Company.” (ECF No. 84-7 at 2.) The Compliance Program also prohibits employees from “misrepresenting a diagnosis for the patient to justify the services or equipment furnished[.]” (ECF No. 85 at 3.) Similarly, the Compliance Program requires employees to submit proposed marketing materials to Defendant’s Marketing Department for approval, as the creation and distribution of the employee’s own marketing material is prohibited. (Id.) These various policies all work in tandem to ensure compliance with health care laws, and violation of the Compliance Program could lead to issues with the Anti-Kickback

Statute and the False Claims Act. (Id.) Ventilators, which Plaintiff marketed for Defendant, may be covered by Medicare when certain criteria are met. (Id.) The material given to physicians explain that when ordering a ventilator for in-home use, the physician should include chart notes with their orders that establish why the ventilator is medically necessary for a specific patient, such as the qualifying diagnosis, the severity of the diagnosis, the planned course of treatment, and results from other prescribed therapies. (Id. at 4.) If the physician believes an in-home ventilator is needed, but the patient

3 does not qualify for Medicare coverage, the patient may bear responsibility for paying for the equipment. (Id.) B. The Audit and Termination of Plaintiff’s Employment Defendant conducts regular audits of documents submitted which establish medical

necessity for ventilator orders prior to submitting those orders to Medicare or other insurers. (Id. at 4; ECF No. 94 at 2.) During one of these audits in the Parkersburg location, Defendant identified “questionable documentation,” consisting of handwritten “template” notes that were “the exact sane cloned type of note” and appeared in multiple patients’ orders. (ECF No. 85 at 4.) While certain information differed in these notes, such as the physician’s signature, patient identification information, and dates, the body of each note “contained nearly identical statements of medical necessity.” (ECF No. 94 at 2.) The results of the audit were reported to Sandra Moreau (“Moreau”), Lincare’s Healthcare Services Manager, and Jennifer Pedersen (“Pederson”), Chief Compliance Officer, who began an investigation. (Id.; ECF No 85 at 4.) On June 3, 2019, Moreau and Pederson, along with Defendant’s Senior Corporation

Counsel Sheila Kalteux (“Kalteux”), traveled to the Parkersburg location to investigate the findings of the audit. (ECF No. 85 at 4.) Once there, the trio interviewed Chad Brady (“Brady”), the manager of the Parkersburg location and Plaintiff’s supervisor; Plaintiff; and several other Parkersburg employees. (Id.) During this investigation, Plaintiff provided Moreau, Pederson, and Kalteux with a binder that contained copies of two “template notes,” with “handwritten template language for ventilator orders” from two different doctor’s offices. (Id.; ECF No. 94 at 3; see generally ECF No. 94-1.) The template notes did not contain any patient information or signatures, but rather only a generic statement of medical necessity. (See generally ECF No. 94-

4 1.) These template notes matched the handwritten notes Defendant discovered during the audit that triggered the investigation. (ECF No. 85 at 5.) Based on the findings of the investigation, Pederson terminated Plaintiff’s employment for violations of the Compliance Program. (Id.) These template notes, which contained nearly identical statements of medical necessity,

were in fact created by the respective physicians’ offices under the supervision of the physician. (ECF No. 94 at 3; ECF No. 94-3 at 4; ECF No. 94-4 at 4.) Ventilator orders require statements of medical necessity, and, because the statements are largely the same for patients who require ventilators, the physicians would then use these template notes to streamline patient care. (ECF No. 94-4 at 4.) While the physicians had copies of these templates at their respective offices, Plaintiff would keep additional copies in the event the physician or the office staff needed one.

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