Schmuckley v. Rite Aid Corporation

District Court, E.D. California·Decided July 14, 2020·No. 2:12-cv-01699·Unknown

Opinion

UNITED STATES OF AMERICA, and the No. 2:12-cv-01699-KJM-EFB STATE OF CALIFORNIA, et al., ex rel. Plaintiffs, v. Defendant. STATE OF CALIFORNIA, ex rel. LOYD Plaintiffs, v. Defendant. Three related motions are before the court. Defendant Rite Aid moves to exclude plaintiffs’ proposed sampling methodology, Sampling Mot., ECF No. 195, and also moves to exclude and strike allegedly untimely evidence and an expert opinion accompanying plaintiffs’ opposition to defendants’ motion to exclude, Def.’s Mot. Strike, ECF No. 208. Plaintiffs move to exclude portions of the expert report and testimony of Rite Aid’s expert Roy J. Epstein, Ph.D. Pls.’ Mot. Exclude, ECF No. 206. On July 15, 2019, the court heard oral argument on the motions. W. Paul Lawrence, Jennifer Bartlett and Brian Barrow appeared on behalf of relator Loyd Schmuckley; Emmanuel Salazar and Bernice Yew appeared on behalf of intervenor State of California; Benjamin Smith appeared on behalf of Rite Aid. At the conclusion of the hearing, the court permitted each party fourteen days to file supplemental briefing addressing two narrow questions posed by the court. Thereafter, the matter was submitted for resolution by written order. Having thoroughly considered the motions, supplemental briefs and arguments at hearing, the court DENIES all the motions for the reasons provided below. A. Relevant Factual Background Given the substance of the pending motions, the court tailors its factual summary to the development of the sampling methodology at issue. In this qui tam action, relator Loyd F. Schmuckley, Jr. and intervenor plaintiff State of California (collectively “plaintiffs”) allege Rite Aid is liable under the False Claims Act (“FCA”) and the California False Claims Act (“CFCA”) for failing to comply with “Code 1 restrictions” as required by Medi-Cal reimbursement regulations. Complaint-in-Intervention (“CII”), ECF No. 75, ¶¶ 4, 6, 118–123. Although it has declined to intervene, the United States remains a real party in interest to this action under 31 U.S.C. § 3730(b)(1). See Not. of Declination, ECF No. 38. As relevant here, when the United States and the State of California (collectively “the government”)1 investigated whether to intervene as parties to this action, there were several layers to their investigation. The first layer was focused on the nature of Rite Aid’s obligations as a provider under the Medi-Cal program. Opp’n to Sampling Mot., ECF No. 202, at 5. As an eligible Medi-Cal provider, i.e., a provider able to receive reimbursement for prescription medications covered by Medi-Cal, Rite Aid was required to execute several provider agreements in which it agreed to comply with all relevant rules and regulations, including certain prescription documentation and certification requirements. CII ¶¶ 20, 52. One such agreement, known as the 1 Where the State of California acts only on its own behalf, the court refers to it as “California” below. Medi-Cal telecommunications provider and biller agreement, or computer media claim (“CMC”) agreement, allows Rite Aid to submit reimbursement claims electronically through the Medi-Cal system. Id. ¶¶ 21, 52. Here, too, Rite Aid agreed to comply with Medi-Cal documentation rules as a condition to utilizing electronic claim submission. Id. ¶ 21. When a provider such as Rite Aid submits a prescription reimbursement claim through the CMC system, the type of prescription dictates the ease with which the claim is processed. Id. ¶¶ 43–47. If a claim prescription involves a Code 12 drug, the system will automatically reject the claim because of heightened restrictions placed on those drugs. Id. ¶ 45. This automatic rejection occurs only when a Code 1 claim is submitted for the first time. Id. For an initial Code 1 claim to be processed, the provider must resubmit the claim with an affirmative statement that Code 1 requirements have been satisfied. Id. ¶ 46. This resubmission and affirmative statement comes in the form of an override code provided by the CMC system. Id. ¶ 47. Under the Medi-Cal provider manual, to deploy an override code to a rejected Code 1 claim, the provider must confirm the Code 1 drug is restricted and the restrictions are satisfied. Id. Rite Aid’s internal policies and computer-based dispensing system largely track these requirements. Id. ¶ 82. Before a Code 1 claim is processed to Medi-Cal, Rite Aid’s system generates a warning to alert the pharmacy of the Code 1 transaction. Id. The Rite Aid associate processing the transaction must then follow a series of verification and documentation instructions to ensure the prescription complies with Code 1 restrictions. Id. If the associate meets these requirements, and the Pharmacist approves, an internally generated override code is used to bypass the Code 1-related warning in Rite Aid’s system. Id.; Opp’n to Sampling Mot. at 7. If, however, the Code 1 prescription does not comply with Code 1 restrictions, then the Rite Aid associate must contact the prescriber to determine whether a change in drug therapy is 2 Code 1 drugs are those “identified on the CDL [Medical List of Contact Drugs] with the asterisk (“*”) symbol” and “require prior authorization in accordance with Cal. Code Regs. tit. 22, § 51003.” CII ¶ 38. necessary or a treatment authorization request (“TAR”)3 must be submitted to Medi-Cal for approval. Id. ¶ 84. In either event, if the prescriber modifies the prescription or provides additional information, the modification must be documented by the associate in hard copy. Id. The documentation must then be scanned into Rite Aid’s system for easy retrieval. Id. ¶ 85. The second layer of the government’s pre-intervention investigation pertains to sampling. Because of the sheer volume of claims processed by Rite Aid through the Medi-Cal system, the government deployed statistical sampling techniques to “determin[e] whether intervention in th[is] qui tam matter was worthy and meritorious.” Opp’n to Sampling Mot. at 7. Specifically, the government sought to “estimat[e] the number of, percentage of, and total payments associated with false claims made by Rite Aid to Medi-Cal for Code 1 drugs.” Id. at 8 (citing Petron Rep., ECF No. 204-1). To do this, the government developed a sampling methodology testing whether a Rite Aid associate, when met with a Code 1 rejection message, “actually performed the requisite Code 1 review, verification, and documentation” before utilizing the override code to process the claim. Id. at 8; CII ¶¶ 97–106. To develop this methodology, the government asked the California Department of Health Care Services (“DHCS”) to pull a subset of paid claims from its rules-based software program known as Symmetry. Opp’n to Sampling Mot. at 9 (citing Yew Decl. ¶ 5, ECF No. 39- 1; Petron Dep., ECF No. 204-3, at 32:4–12). This request produced a batch of 10,810 claims submitted by Rite Aid for Code 1 restricted drugs without a TAR involving service dates from 2010 through 2013. Id. (citing July 27, 2018 Resp. to Interrog., ECF No. 204-4, at 14:13–21; Meixner Decl. ¶ 4, ECF No. 204-5). The government then reviewed Rite Aid pharmacy and prescriber medical records and, based on this review, “probed a random sample” from the batch of 10,810 claims. Id. This review revealed a “statewide pattern of non-compliance.” Id. (citing Yew Decl. ¶¶ 5–7). Next, after consulting with “Rite Aid and Medi-Cal subject matter experts,” the government refined its sample testing and broadened the subset of potentially affected claims. Id. 3 Treatment authorization requests (“TARs”), as defined in Cal. Code Regs. tit. 22, §51003, are described in greater detail below. To do this, California ran multiple data queries in the Medi-Cal claims database, one of which focused on service dates from 2013 through 2014. Id. at 10 (citing Meixner Decl. ¶ 5). The query for 2013–2014 produced over 3.8 million Code

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