United States Ex Rel. Digital Healthcare, Inc. v. Affiliated Computer Services, Inc.

778 F. Supp. 2d 37, 2011 U.S. Dist. LEXIS 42586, 2011 WL 1495928
CourtDistrict Court, District of Columbia
DecidedApril 20, 2011
DocketCivil Action 06-1299 (RBW)
StatusPublished
Cited by34 cases

This text of 778 F. Supp. 2d 37 (United States Ex Rel. Digital Healthcare, Inc. v. Affiliated Computer Services, Inc.) is published on Counsel Stack Legal Research, covering District Court, District of Columbia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
United States Ex Rel. Digital Healthcare, Inc. v. Affiliated Computer Services, Inc., 778 F. Supp. 2d 37, 2011 U.S. Dist. LEXIS 42586, 2011 WL 1495928 (D.D.C. 2011).

Opinion

Memorandum Opinion

REGGIE B. WALTON, District Judge.

The plaintiffirelator, Digital Healthcare, Inc. (“Digital”), brings this qui tam action against defendant Affiliated Computer Services, Inc. (“Affiliated”) under the False Claims Act, 31 U.S.C. §§ 3729-3732 (2006), as well as the false claims act statutes of several states and the District of Columbia. See First Amended Complaint (“Am. Compl.”) ¶¶ 45-138. Digital alleges that by not implementing certain technology, Affiliated is failing to take reasonable measures to determine whether Medicaid claimants have third-party insurance, and is therefore facilitating the submission of false claims to the federal government for Medicaid payments. See id. ¶¶ 11^14. Currently before the Court is Affiliated’s Motion to Dismiss under Federal Rules of Civil Procedure 12(b)(1) and 12(b)(6), asserting that the Court lacks subject-matter jurisdiction over this case and that the plaintiff/relator has failed to plead fraud with the particularity required by Federal Rule of Civil Procedure 9(b). Upon reviewing the Amended Complaint, the defendant’s motion, the plaintiff/relator’s opposition, and the legal *40 memoranda submitted in support of those filings, 1 the Court concludes .for the reasons below that it has subject-matter jurisdiction over the plaintiff/relator’s claims, but that the plaintiff/relator has failed to plead fraud with the required particularity. Affiliated’s motion to dismiss will therefore be granted in part and denied in part.

I. INTRODUCTION

A. Statutory Background

A brief overview of the Medicaid program will help elucidate the plaintifPrelator’s allegations in this case. Medicaid is a joint federal-and-state-funded program that provides medical assistance to individuals whose income and financial resources are insufficient to pay the cost of necessary medical services. See Ark. Dep’t of Health & Human Servs. v. Ahlborn, 547 U.S. 268, 275, 126 S.Ct. 1752, 164 L.Ed.2d 459 (2006). All states and the District of Columbia have elected to participate in the Medicaid program, id.; see D.C. Hosp. Ass’n v. District of Columbia, 224 F.3d 776, 778 (D.C.Cir.2000) (noting the District of Columbia’s Medicaid plan), and pay qualified health providers for a broad range of covered services provided to eligible beneficiaries. “The federal government then reimburses states for a share of their expenditures. The federal share of each state’s program expenditures ranges from 50 to 83 percent.” Def.’s Mem., Declaration of Douglas W. Baruch (“Baruch Decl.”), Exhibit (“Ex.”) 1 (United States Government Accountability Office, GAO 06-862, Medicaid Third-Party Liability, Federal Guidance Needed to Help States Address Continuing Problems (2006)) (“2006 GAO Report”) at 7.

“States have considerable flexibility in designing and operating their Medicaid programs, although they must comply with [certain] federal requirements.” Id. at 2. Operating a state Medicaid program requires the states to engage in a number of activities such as determining the eligibility of individuals who apply for Medicaid assistance, determining what benefits Medicaid will cover, determining which providers are qualified to furnish benefits, processing claims, and maintaining control mechanisms to minimize improper payments and fraud. Def.’s Mem., Baruch Decl., Ex. 2 (Congressional Research Service, State Medicaid Program Administration: A Brief Overview (2005)) (“CRS Overview”) at 2. To help fund these programs, state Medicaid agencies receive a quarterly advance from the federal government based on certain estimates, 42 U.S.C. § 1396b(d)(l) (2006), 42 C.F.R. § 430.30(a) (2010), and at the close of each quarter a state submits an accounting of its actual Medicaid expenditures, 42 C.F.R. § 430.30(c). The states submit this information on a Form CMS-64, entitled Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program. Id.

Federal law requires each state to designate a single state agency to administer or supervise the administration of its Medicaid program. Def.’s Mem., Baruch Decl., Ex. 2 (CRS Overview) at 1. This agency, in turn, will often contract with other public *41 or private entities to perform various Medicaid program functions. Id. For example, some states contract with private companies to operate Medicaid Management Information Systems, which are programs used for claims and other data processing purposes. Id.

Medicaid is intended be a “payer of last resort.” Ahlborn, 547 U.S. at 291, 126 S.Ct. 1752. Thus, “if a Medicaid beneficiary also has another source of payment for health services, that source is to pay instead of Medicaid.” Def.’s Mem., Baruch Decl., Ex. 1 (2006 GAO Report) at 1. In general, state Medicaid agencies are required whenever possible to avoid paying for services for which the state agency has reason to believe another party is legally liable. Id. at 13; see 42 C.F.R. § 433.139(b). Therefore, a state Medicaid agency must “take reasonable measures to determine the legal liability of the third parties who are liable to pay for services furnished under the” state Medicaid plan. 42 C.F.R. § 433.138(a).

B. Factual and Procedural Background

The following information is alleged in the plaintiffirelator’s Amended Complaint. The plaintiff/relator is an “information technology provider and a licensee of intellectual property involving the automated coordination of insurance information between payers and health care providers.” Am. Compl. ¶ 1. The defendant is a corporation that “operates as a Medicaid fiscal agent in thirteen states ... and offers [a] myriad [of] services to the government, including managed care enrollment, eligibility administration, Medicaid claims processing, provider relations[,] and third-party liability.” Id. ¶ 9. The defendant processes “over 475 million Medicaid healthcare claims annually” and is “the nation’s largest Medicaid pharmacy benefits manager.” 2 Id. “Since December 17, 2002, [the] defendant has operated as a Medicaid fiscal agency and/or Medicaid pharmacy benefits manager in the District of Columbia, the Commonwealth of Massachusetts, and the states of Florida, Montana, Tennessee, Louisiana[,] and Texas, as well as other states.” Id. ¶ 16.

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Bluebook (online)
778 F. Supp. 2d 37, 2011 U.S. Dist. LEXIS 42586, 2011 WL 1495928, Counsel Stack Legal Research, https://law.counselstack.com/opinion/united-states-ex-rel-digital-healthcare-inc-v-affiliated-computer-dcd-2011.