Druding v. Care Alternatives, Inc.

164 F. Supp. 3d 621, 2016 WL 727116, 2016 U.S. Dist. LEXIS 21488
CourtDistrict Court, D. New Jersey
DecidedFebruary 22, 2016
DocketCivil Action No. 08-2126(JBS/AMD)
StatusPublished
Cited by11 cases

This text of 164 F. Supp. 3d 621 (Druding v. Care Alternatives, Inc.) is published on Counsel Stack Legal Research, covering District Court, D. New Jersey primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Druding v. Care Alternatives, Inc., 164 F. Supp. 3d 621, 2016 WL 727116, 2016 U.S. Dist. LEXIS 21488 (D.N.J. 2016).

Opinion

OPINION

SIMANDLE, Chief Judge

I. INTRODUCTION

This matter comes before the Court on Defendant Care Alternative, Inc.’s motion to dismiss the first amended complaint. [625]*625[Docket Item 27.] Plaintiff-Relators are former employees of Defendant, a provider of end-of-life hospice care throughout New Jersey. They bring claims on behalf of the United States and the State of New Jersey under the False Claims Act (“FCA”), 31 U.S.C. § 3729 et seq., and the New Jersey False Claims Act (“NJFCA”), N.J.S.A. § 2A:32C-1 et seq., alleging that Defendant routinely fraudulently billed Medicare and Medicaid by admitting and recertify-ing inappropriate patients for hospice care and by engaging in conduct that violates the Stark Act and the Anti-Kickback Statute. Defendant now moves to dismiss the First Amended Complaint for failure to state a claim on the grounds that Plaintiff-Relators have not alleged any cognizable theory of fraud and that Plaintiff-Relators have failed to plead violations of the federal and New Jersey FCA with particularity with respect to any of the courses of conduct alleged. For the reasons discussed below, the Court will grant in part and deny in part Defendant’s motion to dismiss the First Amended Complaint.

II. BACKGROUND1

Defendant is a for-profit provider of end-of-life hospice care throughout New Jersey. (Am. Compl. ¶ 2.) Defendant organizes the state into five regions for administrative purposes; Plaintiff-Relators were members of the Southwest team when they were employed by Defendant in the positions of Regional Manager, Chaplain, Registered Nurse Case Manager, and Community Liaison. (Id. ¶¶ 1, 3.)

In essence, Plaintiff-Relators 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. Defendant purportedly directed its staff to “manipulate and/or change” patients’ diagnoses to qualify for hospice care under Medicare’s Hospice Eligibility Guidelines. (Id. ¶¶ 12, 27.) Staff were directed to re-write medical records in order to meet the hospice criteria and re-create “missing” documents. (Id. ¶¶ 18, 22, 26, 27.) The Regional Manager was instructed to review patient records and identify symptoms that would justify the patient’s recertification for a longer hospice stay. (Id. ¶ 29.) Plaintiff-Relators identify 15 patients whose symptoms allegedly did not match Medicare’s criteria for hospice care. (Id. ¶ 25.) Plaintiff-Relators aver that nurses were told, inter alia, to “back date the paperwork” and to change diagnoses to keep patients on the program. (Id.)

Plaintiff-Relators further allege that Defendant engaged in an aggressive marketing campaign to bring in more patients. (Id. ¶¶ 4, 23.) Defendant had an “unlimited budget” to spend on meals, gifts, and facility perks for physicians, administrators, directors, and social workers to induce referrals. (Id. ¶¶ 20, 43.) Defendant allegedly promised community liaisons “elevated levels of care, extra aids, full time nurses, reimbursement [sic] for non-hospice specific needs” and gifts to “bring in the bodies.” (Id. ¶¶ 34, 48.) Community liaisons were allegedly directed to take gifts and meals to facilities where there were “service failures” but not to document the gifts in their daily reports. (Id. ¶¶ 45-47.) Plaintiff-Rela-tors also describe incidents where Defendant’s practices resulted in billing irregularities discovered by its partner facilities. (Id. ¶¶ 35, 37, 38, 51, 52, 54.) Certain facilities were paid to correct billing errors [626]*626while others allegedly decided to leave Defendant’s network because of billing issues. (Id.)

Plaintiff-Relators filed the instant qui tam action for violation of the FCA on behalf of the United States in 2008 in camera and under seal in accordance with 31 U.S.C. § 3730(b) and amended their complaint in 2013 to add state law claims under New Jersey’s FCA. [Docket Items 1, 12.] After nearly seven years investigating Plaintiff-Relators’ claims, the United States elected not to intervene in the action. [Docket Item 15.] A redacted copy of the First Amended Qui Tam Complaint was thereafter served upon Defendant on July 29, 2015. [Docket Item 16.] Defendant filed a motion to dismiss [Docket Item 27.] Plaintiff-Relators filed an opposition [Docket Item 33] and Defendant filed a reply. [Docket Item 39.] Plaintiff-Relators requested and were granted leave to file a sur-reply. [Docket Items 40, 41, 42.] The United States thereafter filed a statement of interest, without moving to intervene in the case, pursuant to 28 U.S.C. § 517. [Docket Item 43.] Defendant was granted leave to file a response to the Government’s statement. [Docket Item 46.]

III. STANDARD OF REVIEW

When considering a motion to dismiss a complaint for failure to state a claim upon which relief can be granted under Fed. R. Civ. P. 12(b)(6), a court must accept as true all well-pleaded allegations in the complaint and draw all reasonable inferences in favor of the plaintiff. See Erickson v. Pardus, 551 U.S. 89, 93-94, 127 S.Ct. 2197, 167 L.Ed.2d 1081 (2007) (per cu-riam).

A motion to dismiss may be granted only if a court concludes that the plaintiff has failed to set forth fair notice of what the claim is and the grounds upon which it rests that make such a claim plausible on its face. Ashcroft v. Iqbal, 556 U.S. 662, 129 S.Ct. 1937, 173 L.Ed.2d 868 (2009); Bell Atlantic Corp. v. Twombly, 550 U.S. 544, 127 S.Ct. 1955, 167. L.Ed.2d 929 (2007). Although the court must accept as true all well-pleaded factual allegations, it may disregard any legal conclusions in the complaint. Fowler v. UPMC Shadyside, 578 F.3d 203, 210-11 (3d Cir.2009). A plaintiff must plead sufficient facts to “raise a reasonable expectation that discovery will reveal evidence of the necessary element,” Twombly, 550 U.S. at 556, 127 S.Ct. 1955, and “[a] pleading that offers labels and conclusions or a formulaic recitation of the elements of a cause of action will not do.” Iqbal, 556 U.S. at 678, 129 S.Ct. 1937.

In the present case, Rule 9(b) of the Fed. R. Civ. P. requires particularized pleading for the conduct underlying fraud claims, including those under the False Claims Act. Foglia v. Renal Ventures Mgmt., LLC, 754 F.3d 153, 155 (3d Cir.2014). Under Rule 9(b), the “circumstances” of the alleged fraud must be pled with enough specificity to “place defendants on notice of the precise misconduct with which they are charged.” Seville Indus. Mach. Corp. v. Southmost Mach. Corp., 742 F.2d 786, 791 (3d Cir.1984).

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164 F. Supp. 3d 621, 2016 WL 727116, 2016 U.S. Dist. LEXIS 21488, Counsel Stack Legal Research, https://law.counselstack.com/opinion/druding-v-care-alternatives-inc-njd-2016.