Covington v. Sisters of Third Order of St. Dominic of Hanford, Cal.

61 F.3d 909, 1995 U.S. App. LEXIS 27460, 1995 WL 418311
CourtCourt of Appeals for the Third Circuit
DecidedJuly 13, 1995
Docket93-15194
StatusUnpublished
Cited by2 cases

This text of 61 F.3d 909 (Covington v. Sisters of Third Order of St. Dominic of Hanford, Cal.) is published on Counsel Stack Legal Research, covering Court of Appeals for the Third Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Covington v. Sisters of Third Order of St. Dominic of Hanford, Cal., 61 F.3d 909, 1995 U.S. App. LEXIS 27460, 1995 WL 418311 (3d Cir. 1995).

Opinion

61 F.3d 909

NOTICE: Ninth Circuit Rule 36-3 provides that dispositions other than opinions or orders designated for publication are not precedential and should not be cited except when relevant under the doctrines of law of the case, res judicata, or collateral estoppel.
Janet M. COVINGTON; Stanley H. Sidicane, Plaintiffs-Appellants,
United States of America, Plaintiff-Appellee,
v.
SISTERS OF the THIRD ORDER OF ST. DOMINIC OF HANFORD,
CALIFORNIA, d/b/a Sacred Heart Hospital, et al., Defendants.

No. 93-15194.

United States Court of Appeals, Ninth Circuit.

Argued and Submitted March 15, 1994.
Decided July 13, 1995.

Appeal from the United States District Court for the Eastern District of California, No. CV-87-00632-OWW; Oliver W. Wanger, District Judge, Presiding.

E.D.Cal.

REVERSED AND REMANDED.

Before: D.W. NELSON and BEEZER, Circuit Judges, and LETTS,* District Judge.

MEMORANDUM**

Relators Janet Covington and Stanley Sidicane ("the Relators") brought this action as qui tam plaintiffs pursuant to the False Claims Act, 31 U.S.C. Sec. 3729-3731. On December 10, 1992, the district court entered a final order that effectively granted judgment to the United States and terminated the proceedings. The Relators appeal, seeking either our determination that they were entitled to participate in the settlement or a remand to the district court with instructions to resolve the dispute on its merits. We have jurisdiction pursuant to 28 U.S.C. Sec. 1291. We agree with the Relators that resolution of this dispute on the merits is necessary. We reverse and remand.

* In November 1987, the Relators filed a qui tam complaint on behalf of themselves and the United States government, pursuant to the False Claims Act ("the Act"), 31 U.S.C. Sec. 3730. The complaint alleged that Sacred Heart Hospital, a private hospital in Hanford, California, the Catholic Health Corporation, and others (collectively "Sacred Heart") had violated the Act in connection with their participation in the federal Medicare program. The Relators alleged two types of wrongdoing. First, they claimed that Sacred Heart personnel had fraudulently recoded diagnoses to receive higher reimbursement from the fiscal intermediary. This "upcoding" claim is not at issue in this appeal. Second, the Relators asserted that Sacred Heart personnel knowingly submitted false claims for Medicare payments based on an inflated reimbursement rate. This "overpayment" claim is at issue here.

The overpayments began in January 1984 when auditors for Blue Cross of California, the fiscal administrators of the Medicare program in the state, applied an incorrect geographical factor to compute Medicare reimbursements to Sacred Heart for medical services that the hospital had rendered. Although Sacred Heart is a rural hospital located in Kings County, California, it received payments as though it were an urban hospital located in Alameda County, California. The urban factor resulted in a higher rate of reimbursement than the rate to which Sacred Heart was entitled. The Relators' complaint alleged that Sacred Heart personnel knew of the incorrect overpayments for several years, yet continued to accept and use the payments.

After investigation and negotiations, during which discovery by the Relators was not permitted, the government settled both claims. Early in 1988, the government required Sacred Heart to make restitution on the overpayment claim through an Administrative Settlement, under which Blue Cross would withhold a portion of Sacred Heart's future Medicare reimbursements until the entire amount, approximately $2.6 million, had been repaid. The Relators asserted a right under the Act, see 31 U.S.C. Sec. 3730(f), to a percentage of the government's recovery, but the government asserted that the Relators were not entitled to any share in that recovery because the government had accepted simple restitution for the overpayment amount after concluding that Sacred Heart's conduct was not fraudulent.

The Relators continued to assert their entitlement to a portion of the recovery for the overpayment violations as part of the negotiations for settlement of the upcoding violations. In January 1991, the Relators, Sacred Heart, and the government reached a Settlement Agreement ("the Agreement") by which the Relators would receive a portion (twenty percent plus interest) of the upcoding recovery. The Agreement also provided that the Relators' claim to a portion of the Administrative Settlement of the overpayment claim would be resolved through an expedited mechanism: the issue would be presented via "motion and stipulated facts with no discovery permitted." If the parties were unable to agree on undisputed facts, "the parties [were to] thereafter proceed as if a motion for summary judgment had been filed under the provisions of the [Federal Rules of Civil Procedure]." The government agreed to provide all relevant documents, except those subject to a protective privilege. Pursuant to the Agreement, the district court dismissed all claims except the participation of the Relators in the overpayment recovery that is the subject of this appeal.

The government provided copies of five letters exchanged between Sacred Heart and Blue Cross from late January 1987 through December 1987, which initially stated that the hospital reimbursements were at "inappropriate" rates. The government withheld its own investigative reports and interview records with Sacred Heart personnel. Because the government claimed privilege for these crucial discovery documents, the Relators moved for a discovery order. The district court determined that the asserted privileges were inapplicable and ordered production.

Based on those documents, the government and the Relators prepared a statement of admitted facts to be submitted in support of the summary judgment motion. Each side also submitted additional facts. Attached to its opposition, the government submitted the declarations of Wallace Flemming, Sacred Heart's Chief Executive Officer during the period of the overpayments, and Norman Siegal, the government investigator who claims to have prepared the final administrative report on the overpayment claim. The government also submitted excerpts from a January 1989 deposition of Mario Rocha, the hospital's Chief Financial Officer during the period of the overpayments.

The following facts are uncontested. Sacred Heart learned about the overpayments as early as June 1984 when, according to Rocha's deposition, Flemming informed Rocha that he had contacted Blue Cross, the fiscal administrator, to tell them that the reimbursement rate was inappropriate. Blue Cross told Flemming that the rate was correct, and that "Flemming was wrong about any mispayment." Flemming contacted a law firm in 1986, and the firm advised Flemming to send a letter to Blue Cross. Meanwhile, Rocha established a line item in Sacred Heart's budget to track the estimated overpayments as a "liability to third parties" for accounting purposes. Rocha was not sure of the cause of the overpayment, but he suspected a mistake in the urban-rural coding.

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61 F.3d 909, 1995 U.S. App. LEXIS 27460, 1995 WL 418311, Counsel Stack Legal Research, https://law.counselstack.com/opinion/covington-v-sisters-of-third-order-of-st-dominic-of-hanford-cal-ca3-1995.