GUARDIOLA v. RENOWN HEALTH

District Court, D. Nevada·Decided March 4, 2020·No. 3:12-cv-00295·Unknown

Opinion

DISTRICT OF NEVADA

* * * UNITED STATES OF AMERICA, ex rel. Case No. 3:12-cv-00295-LRH-CLB CECILIA GUARDIOLA, Plaintiff/ Relator, v. RENOWN HEALTH, RENOWN REGIONAL MEDICAL CENTER, and RENOWN SOUTH MEADOWS MEDICAL CENTER, Defendants. Before the court is relator Cecilia Guardiola’s motion to award her a share of the proceeds recovered administratively and separately by the United States from defendants Renown Health, Renown Regional Medical Center, and Renown South Meadows Medical Center (collectively “Renown”). ECF No. 231. The United States (“the Government”) filed a response (ECF No. 232), and Guardiola replied (ECF No. 235). Guardiola argues that the court should award her a share of the proceeds recovered separately by the Government via the Recovery Audit Contractor (“RAC”) and/ or the Medicare Administrative Contractor (“MAC”), as they constitute an “alternate remedy” under the False Claims Act, 31 U.S.C. § 3730(c)(5), (“FCA” or “the Act”). The Government argues that these proceeds are not an alternate remedy because the RAC audits began in 2010, two years before Guardiola brought her qui tam suit, and because the Government’s recovery did not entirely moot or preclude Guardiola’s qui tam suit. The court agrees with Guardiola; it therefore grants her motion and awards her $1,021,448.52, which represents a 29% share of the recovered On June 1, 2012, Guardiola filed this qui tam action alleging that Renown “defraud[ed] government-funded health insurance programs” through improper billing, in violation of the FCA, 31 U.S.C. § 3729 et seq. ECF No. 107 at 2-3. Pursuant to 31 U.S.C. § 3730(b)(2), Guardiola filed the complaint under seal, and it was served upon the United States for review. The Government extended the 60-day time period for review several times, ultimately declining to intervene in the action in mid-September 2013. Guardiola filed an amended complaint in January 2014 (ECF No. 17), which was served on Renown (ECF No. 18).1 “To supplement CMS’s [Centers for Medicare and Medicaid Services] efforts to protect the fiscal integrity of the Medicare program, Congress enacted the RAC program. Congress told the Secretary [of the Department of Health and Human Services] to conduct a demonstration project using RACs to ‘identify underpayments and overpayments and recoup overpayments under the Medicare program.’” Palomar Medical Center v. Sebelius, 693 F.3d 1151, 1156 (9th Cir. 2012) (quoting Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (“MMA”), Pub.L. No. 108-173, § 306(a), 117 Stat. 2066, 2056 (2003)). This demonstration project ran from March 2005 to March 2008 and culminated in “RACs successfully correcting more than $1 billion in improper Medicare payments.” Id. at 1157. Given this success, “Congress made the RAC program a permanent part of the Medicare Integrity Program and expanded its coverage to all states.” Id. (citing 42 U.S.C. § 1395ddd(h)(1), (3)). Beginning in October 2008, HDI was awarded the contract for RAC Region D, and with the CMS’s approval, “performed patient status reviews, which may have included services billed by Renown.” ECF No. 231-2 at 5; ECF No. 231-4 at 7. The Government’s records show that HDI began sending Renown document requests pertaining to these reviews in 2010. See ECF No. 232- 2. The record provides that HDI’s RAC contract was an “options years” contract—there were series of 1-year contracts that ran from 2008 to 2018, which CMS had the option of canceling or extending each year (though it always renewed the contract). ECF No. 231-2 at 6, 8; ECF No. 231- 4 at 7. The RAC’s contract was in part governed by the Statement of Work, which, in relevant part, provided that the RAC was to prevent overlap with other contractors, CMS, OGC, DOJ, OIG, and/ or other law enforcement entities performing potential fraud reviews. See ECF No. 231-5. To ensure that more than one entity did not review a claim, the RAC reviewed the “RAC data warehouse” to see if a claim was “excluded” (another entity was reviewing, or had reviewed, the claim) or suppressed (the claim was not to be reviewed). ECF No. 231-4 at 9. CMS additionally had the power to stop an audit by contacting the RAC (ECF No. 231-4 at 12), and it could issue a “stop-work order” which prevented the RAC from performing certain audit activities, including “issuing additional requests for medical records to a provider or issuing additional improper payment notifications,” (ECF No. 231-2 at 7). CMS could also effect a “litigation-hold,” which it did in November 2017 in regards to this litigation. ECF No. 231-2 at 20. As stipulated to by the parties, during the pendency of Guardiola’s qui tam suit, the Government recovered $3,461,612.56 from Renown via the RAC.2 ECF No. 221 ¶ 3. Guardiola and Renown eventually reached a settlement agreement in her qui tam suit in July 2016, resulting in a $9.5 million dollar award to the United States, and a stipulated dismissal of Renown with prejudice. ECF Nos. 182 & 183. Guardiola, as the relator in this qui tam action, was awarded a 29 percent share of this settlement recovery, amounting to $1,707,324. ECF No. 183-1 at 3. During her qui tam suit, Guardiola discovered that the Government had already recovered a portion of the covered conduct of her qui tam suit via the RAC and MAC. Therefore, she did not pursue these proceeds in her settlement with Renown and reserved the right to claim a relator’s share of these proceeds as an “alternate remedy.” ECF No. 180; ECF No. 183-1 at 6. Following the settlement, Guardiola motioned this court for a share of the alternative remedy. ECF No. 179. The United States did not directly respond to this motion, but instead moved for leave to file an amicus curiae brief in opposition. ECF No. 184. On September 14, 2016, the court ruled it lacked jurisdiction to determine Guardiola’s proceeds because the Government was not a party to the original action. ECF No. 190. When Guardiola moved to amend her complaint

2 As provided by the parties, because the proceeds recovered by the MAC were “miniscule” in comparison to those recovered by the RAC, the parties reference only the RAC, though they stipulated that the total (ECF No. 191), the court ruled that because sovereign immunity would bar her claim, amendment was futile (ECF No. 197). Guardiola appealed these rulings to the Ninth Circuit (ECF No. 198), where the Government reversed its position and asserted that the FCA acts as a waiver of sovereign immunity (see United States of America ex rel. Cecilia Guardiola v. Renown Health and United States of America (Intervenor), No. 16-17205, Dkt 22-2 (9th Cir. 2017)). Guardiola then moved this court to issue an indicative ruling under Rule 62.1 (ECF No. 204), which the court granted (ECF No. 206). Shortly thereafter, the Ninth Circuit remanded the matter to this court for the limited purpose of enabling the court to consider Guardiola’s 60(b) motion (ECF No. 207), and this court vacated its prior rulings (ECF No. 208). Guardiola then voluntarily dismissed her appeal. ECF No. 209. The court allowed limited discovery to be conducted on Guardiola’s alternate remedy theory. ECF Nos. 220 & 224. In relavant part, the parties also stipulated to the following facts:

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