Judith Robinson v. Healthnet, Inc.

124 F.4th 511
Court of Appeals for the Seventh Circuit·Decided December 26, 2024·No. 23-2728·Published

Opinion

In the

United States Court of Appeals For the Seventh Circuit

No. 23–2728

UNITED STATES OF AMERICA, ex rel., JUDITH ROBINSON, Plaintiff,

and

STATE OF INDIANA, Plaintiff-Appellee

v.

HEALTHNET INC.,

Defendant-Appellee.

APPEAL OF: JUDITH ROBINSON

Appeal from the United States District Court for the Southern District of Indiana, Indianapolis Division. No. 1:19-cv-4258-JRS-TAB — James R. Sweeney II, Judge.

ARGUED MARCH 29, 2024 — DECIDED DECEMBER 26, 2024

Before ROVNER, ST. EVE, and PRYOR, Circuit Judges.

2 No. 23-2728

ROVNER, Circuit Judge. On its face, this is a qui tam action brought by Dr. Judith Robinson, the relator, on behalf of the United States and the State of Indiana, against HealthNet, a federally qualified health center in Indiana which provides, among other services, obstetric and gynecologic services to individuals at or below the federal poverty level. Because we find that the relator lacks standing to bring Count III of her amended complaint and the settlement between Indiana and HealthNet is fair, adequate, and reasonable, we affirm the holdings of the district court.

I.

HealthNet employed Dr. Robinson from 2005 until 2013.

During her time at HealthNet, Dr. Robinson witnessed certain practices that caused her concern, including discrepancies between the way certain patient services were performed and how those services were billed and recorded. For example, Medicaid will only reimburse ultrasound readings if those readings are done during a face-to-face encounter between the doctor and the patient. In her wrap-around claims—called “wrap-around” due to the reimbursement calculation and structure for the underlying service—Dr. Robinson alleged that HealthNet doctors would review ultrasound photographs at the end of the day, rather than during a face-to-face encounter, but would bill Medicaid as though the doctor had read the ultrasound during a face-to-face encounter. As a result of her concerns, Dr. Robinson brought a qui tam suit, United States & Indiana ex rel. Robinson v. Indiana University Health, Inc., et al., No. 1:13-cv-2009-TWP-MJD (S.D. Ind. 2013) (“Robinson I”), on behalf of the United States and the State of Indiana alleging violations of the federal Anti-Kickback

No. 23-2728 3

Statute and False Claims Act and the Indiana False Claims and Whistleblower Protection Act.

When an individual brings a qui tam suit, he or she is termed the “relator.” The relator stands in the shoes of the government, and he or she prosecutes the action on the government ’s behalf. The government is permitted to intervene in the action, but it is not required to do so, and the relator may continue the action even if the government does not intervene . However, if the government does intervene, it takes primary responsibility for prosecuting the action. If the action successfully results in a recovery for the government, the relator is entitled to a share of that recovery. The size of the share varies from suit to suit, and it depends on the specific characteristics of the action, including whether the government intervened.

In April 2017, Dr. Robinson reached a settlement with HealthNet in Robinson I. At the time of settlement, the value of the wrap-around claims could not be determined because Indiana had not completed its reconciliation process. As a result , the settlement agreement specifically excluded the wrap- around claims and dismissed the remaining claims with prejudice . The wrap-around claims, by contrast, were dismissed without prejudice. The settlement awarded Dr. Robinson a relator ’s share of 27.5% of the $18 million recovered by the United States and Indiana.

By March 2018, the reconciliation process concluded, and the value of the wrap-around claims was determined to be $1,454,541.91. A dispute arose between Indiana and the United States about each entity’s liability for the relator’s share. The federal government reimburses states that participate in Medicaid for a portion of their Medicaid expenditures.

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The reimbursement amount is based on the Federal Medical Assistance Percentage (“FMAP”), which is tied to each state’s per capita income. For the period of the wrap-around claims, Indiana’s FMAP was approximately 66%. Thus, in Indiana’s view, it only had liability to Dr. Robinson for a relator’s share based on 33% of the recovery because the federal government had reimbursement responsibility for 66% of the total recovery . In the United States’s view, Indiana had never submitted these wrap-around claims to it for reimbursement and, therefore , it had not suffered a loss. HealthNet, for its part, had refused to accept funds from Indiana for the wrap-around claims.

In June 2019, Dr. Robinson moved to reopen Robinson I. In her motion, Dr. Robinson claimed that she reached an oral settlement agreement with HealthNet as to the wrap-around claims and, now that those claims could be valued, she wished to enforce the oral settlement agreement. Magistrate Judge Dinsmore, to whom the district court judge referred the motion to reopen, held a status conference and denied the motion to reopen in a minute entry. In that entry, Judge Dinsmore wrote that the court no longer had subject matter jurisdiction over the wrap-around claims because they had been dismissed, but that Dr. Robinson could file another suit for the purposes of resolving whether the United States or the State of Indiana should pay Dr. Robinson’s share.

Instead of following Judge Dinsmore’s suggested course of action, Dr. Robinson then filed this suit, Robinson II, which was assigned to Judge Sweeney, against one defendant, HealthNet. In her complaint, Dr. Robinson realleged the substantive allegations related to the wrap-around claims from her complaint in Robinson I, as well as other claims that she

No. 23-2728 5

had also raised and settled in Robinson I. See e.g., R. 9 at 11 (alleging that HealthNet submitted claims for the administration of Depo-Provera birth control as a physician-patient encounter when, in reality, the Depo-Provera shot was administered by a nurse). Count I of Robinson II alleged violations of the federal False Claims Act and Count II alleged violations of the Indiana False Claims Act. Dr. Robinson also included Count III, which was new to the Robinson II complaint. Count III sought to enforce the alleged oral settlement agreement reached between Dr. Robinson and HealthNet and requested that the court “use its equitable powers” to enforce the alleged oral agreement. R. 9 at 18. Notably, Dr. Robinson does not allege that either the State of Indiana or the United States has failed to abide by the oral settlement agreement.

The United States declined to intervene in Robinson II, but Indiana exercised its right to intervene and made a series of motions that changed the scope of the litigation. Specifically, Indiana sought to dismiss all claims except for the wrap- around claims as barred under res judicata. As to the wrap- around claims, Indiana argued that both the federal and Indiana False Claims Act statutes have a six-year statute of limitations that is triggered when the violation occurs, and a second three-year statute of limitations that is triggered when the government learns of the false claim. R. 20 at 16–17. Dr. Robinson filed Robinson II on October 17, 2019; thus any violations that occurred before October 17, 2013 were barred unless the federal government and Indiana learned of the alleged violations within the three years prior to the filing of Robinson II. Id. However, Dr. Robinson filed Robinson I on October 29, 2014, which alerted the government entities to the alleged violations . Id. Thus, any wrap-around claims that occurred before October 17, 2013 were time-barred. Id. Dr. Robinson did 6 No. 23-2728

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Judith Robinson v. Healthnet, Inc., 124 F.4th 511 (7th Cir. 2024).

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