United States ex rel. Derrick v. Roche Diagnostics Corp.

318 F. Supp. 3d 1106
District Court, E.D. Illinois·Decided June 7, 2018·No. No. 1:14-cv-04601·Published·Cited by 8 cases

Opinion

Elaine E. Bucklo, United States District Judge

In this qui tam action, plaintiff-relator Crystal Derrick ("relator") sues her former employer Roche Diagnostics Corporation, and its affiliate Roche Diabetics Care, Inc., (collectively "Roche" or the "Roche defendants"),1 along with Humana, Inc., and Humana Pharmacy, Inc., (collectively "Humana" or the "Humana defendants"), alleging that they violated the False Claims Act ("FCA" or "the Act"), 31 U.S.C. §§ 3729 - 3733, by engaging in a business scheme in violation of the Anti-Kickback Statute ("AKS"), 42 U.S.C. § 1320a-7b(b), and by retaliating against her for raising concerns about the lawfulness of that scheme. Roche and Humana have each filed a motion to dismiss the complaint, and relator has moved to strike certain documents that Roche filed in support of its motion. For the reasons that follow, defendants' motions are denied except that Count IV of the complaint is dismissed against Humana, and relator's motion to strike is denied as unnecessary.

I.

The following summary is drawn from the second amended complaint ("SAC" or "the complaint"), whose factual allegations I accept as true for present purposes. See AnchorBank, FSB v. Hofer , 649 F.3d 610, 614 (7th Cir. 2011). The Roche defendants manufacture and market blood glucose monitoring products used by individuals with diabetes. SAC ¶¶ 5-7, 49. Humana is *1110an insurance company that offers health insurance plans nationwide, including Medicare Advantage plans, which Humana provides pursuant to contracts with the federal government. Id. ¶¶ 8, 47-48, 72. Humana maintains formularies on which it lists products covered by its Medicare Advantage and other federally funded plans. Id. ¶¶ 42-49. Humana Pharmacy operates a mail-order pharmacy called RightSource, which primarily disburses to members covered by government insurance programs. Id. ¶ 48.

The Medicare Advantage Program, otherwise known as Medicare Part C, contracts with private insurance companies called Medicare Advantage Organizations ("MAOs"), of which Humana is one. The Centers for Medicare & Medicaid Services ("CMS") compensates MAOs at a capitated rate for the delivery of benefits. To participate in the Medicare Advantage program, MAOs must submit bids to CMS every year in which they offer to provide services for a specified amount per member, per month. Each participating MAO must then enter into a contract with CMS, the terms of which require the MAO to comply with certain laws, including the AKS and the FCA. 42 C.F.R. § 422.503(a), § 422.504(h). To receive payment for services provided under the Medicare Advantage program, MAOs must submit monthly payment requests to CMS along with monthly reports certifying that "all information submitted to CMS in this report is accurate, complete, and truthful." SAC ¶¶ 72, 74-77.

Prior to the events giving rise to the complaint, Roche contracted with Humana to make its glucose monitoring products available on Humana's Medicare Advantage and RightSource formularies. Relator was a national accounts manager for Roche from October 2012 to December 2013 and was involved in overseeing Roche's account with Humana. Id. ¶¶ 4, 48-51. According to the complaint, Humana notified Roche in March of 2013 that it would be terminating an agreement under which Roche's products were available on Humana's RightSource formularies. Id. ¶ 50. Relator describes this news as a "significant blow" to Roche's business. Id.

In May of 2013, relator discovered that Humana had not complied with certain terms of its formulary agreements with Roche. Id. ¶ 51. As a result of Humana's noncompliance, Roche had paid rebates to Humana that were not actually owed. Id. Relator met with Bethany Stein, a contract strategist at Humana, to discuss Roche's rebate overpayments. Id. ¶ 52. Stein acknowledged the overpayments and agreed "that it would be appropriate for Roche to quantify" the amount it had overpaid. Id. In a subsequent conversation, Stein indicated that "due to the potentially large size of the reimbursement" it owed Roche, Humana had decided to have an auditor perform a formal calculation. Id. ¶ 54.

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United States ex rel. Derrick v. Roche Diagnostics Corp., 318 F. Supp. 3d 1106 (illinoised 2018).

318 F. Supp. 3d 1106 (United States ex rel. Derrick v. Roche Diagnostics Corp.) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.

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